HospitalInspections.org

Based on review of 4 medical records and pertinent policies and procedures, it was determined that the hospital failed to complete an operative report immediately after surgery for 1 of 4 records reviewed for surgical consents.

Per Rules and Regulations, Article VI, Section 6.2 'Post Procedure Protocol', within facility's Medical Staff bylaws:

"a) For every procedure performed in an operating room and/or under sedation, a progress note containing specific information will be entered in the medical record immediately after the procedure."

Patient #1 (P1) presented to the Emergency Department after an injury sustained at home. P1 was admitted, and it was determined that a surgical intervention was needed. The surgery was performed two days after the admission, and an operative report was not completed until 15 hours after the surgical procedure. No evidence of a brief operative note or a progress note regarding the procedure were found in P1's record.