HospitalInspections.org
Bringing transparency to federal inspections
RIVER CREST HOSP
CONTENT OF RECORD: FINAL DIAGNOSIS
Tag No.: A0469
Based in a review of documentation and policy it was determined the facility failed to ensure that medical records were completed in a timely manner.
Findings were:
Review of the facility based Medical Executive Meeting minutes for January 31, 2014, revealed a delinquent medical documentation rate of 8 % for a total of 225 discharges for the month of November. The delinquency of 25 history and physicals for the fourth quarter was also noted with a rate of 4 %.
According to the Hospital Medical Record Statistics Form the average medical delinquency rate for the last four quarters of 2013 was 9 %.
Facility based Medical Staff Rules and Regulations stated in part,
"IV. Medical Records ...
C. All medical records shall be completed within the specification of III, A., or III B., and ready for filing from discharge of the patient. No record may be filed until completed by the responsible practitioner or ordered filed by the Medical executive Committee."
The above findings were confirmed in an interview with staff members # 16 and 17 on 02/05/14.