HospitalInspections.org

Based on record review, interview and policy review the Critical Access Hospital (CAH) failed to ensure time/date/signature of the medical record entries for 3 of 5 patients (P1, P2, P3). Findings include:

P1 medical record contained physician's progress note for 9/13/11 which lacked physician's signature and were not timed. P1, was admitted on 9/12/11 for an asthma condition.

P2 medical record contained a physician's progress note dated for 9/20(no year listed) lacked the time and date of the entry.

P3 had an physician progress note of 9/18/11 which lacked the time entry of the record. The patient was admitted 9/12/11 with asthma complications.

On 9/29/11 at 12:45 p.m. the Health Information Officer confirmed these medicals records lacked the necessary time, dates and signatures of the physician.

Review of the CAH's Medical Records policy with the most recent revision dated 9/7/2011 specified that "All entries in the patient's medical record must be dated, timed and signed, this will include the physician signature verifying telephone and verbal orders".


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