HospitalInspections.org

Based on review of medical records for Patient #1, hospital policies, and interviews, it was determined the medical record contained illegible signatures, inaccuracies, and was incomplete.

Findings include:

The CAH's policy on "General Charting Requirements" included: "4. Each chart form must be properly identified with the patient's name, patient ID number and any other required identification data...8. Entries must be signed legibly with the care giver's first initial, last name, and status where specified in documentation form procedures...Confidentiality and Record Controls 1. The medical record of discharged patients must be sent to the Medical Records Department within 24 hours."

The Emergency Room (ER) policy "Verbal Orders" includes: "Verbal orders are to be signed by the ordering physician within 24 hours of placing the order."

A review of Patient #1's medical records revealed illegibility, inaccuracies, and incompleteness, as evidenced by the following:

An ER nursing assessment dated 2/15/11, had an illegible signature. The Medication Administration Record included the patient's pain level, vital signs and that 2 liters of oxygen was placed on the patient. At the bottom of the page was a space with "RN Print Name" and another space with "RN Signature." The printed name had only the first two letters that were legible and the last name was illegible as was the signature of the RN name that was in the following space.

Patient #1's visit on 2/15/11 had the following verbal order written by the nurse on 2/16/11 at 0012 hours: "Cancel above orders. V.O. (Verbal Order) Dr (name of Physician #1)." This order had an illegible signature. The ER Nurse Manager acknowledged it was not legible. She stated she knew who the nurse was since she has worked with this nurse for some time.

The Admission form with patient #1's insurance and other pertinent information revealed the visit on 2/15/11 had the attending physician with the name of Physician #2. Each page of the record had the stamped identification information, which also revealed Physician #2 as the attending physician. The ER physician assessment and physician orders all indicated Physician #1 was the attending physician. There were no notes or orders by Physician #2. The ER Nurse Manager acknowledged Physician #1 was the physician that treated Patient #1 and not Physician #2 as noted on the record. She stated the admitting information was inaccurate. This patient returned to the hospital to have the staples removed on 2/25/11. The Admission record and the identification stamp was again noted to be Physician #2. However, the attending physician was Physician #3.

The physician's verbal order on 2/15/11, to cancel the orders was not signed by the physician as required within 24 hours. The medical record was printed for this surveyor to review and that was the last entry. However, when the original chart was reviewed an hour later, there was an additional notation in pencil reporting: "Original order sheet sent for physician to complete due to no longer working here." This newly added note indicates the record was not reviewed by medical records for completeness or attempts to obtain the physician's signature until the chart was reviewed that day. The facility requires verbal orders to be signed within 24 hours. The CNO acknowledged the record is expected to be completed within 30 days from the time of discharge. She acknowledged the Medical Records Department should have immediately reviewed and obtained the physician's signature on the verbal order.