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SCRIPPS MERCY HOSPITAL
MEDICAL STAFF RESPONSIBILITIES - H&P
Tag No.: A0358
Based on interview and record review, the hospital failed to ensure that a History and Physical (a critical component of a patient encounter in which information relevant to a present complaint is obtained) was completed for 1 of 40 sampled patients (Patient 1) within 24 hours of her admission to Hospital A. The lack of a history and physical in a patient's medical record could hinder health practitioners in their treatment plan for the patient due to the lack of documentation of the patient's past medical history, allergies, comorbitities (existing medical diagnoses), and overall medical condition.
Findings:
Patient 1 was admitted to the hospital on 10/29/13 with a diagnosis of bilateral leg wounds, according to the Admission Facesheet. A review of Patient 1's medical record was conducted on 11/4/13 at 10:45 A.M. There was no evidence in Patient 1's medical record that her attending physician had either written or dictated a complete History and Physical.
A review of the hospital's Medical Staff Bylaws indicated that "Completion of a physical examination and medical history shall be done within twenty-four (24) hours after admission. This requirement may be satisfied by a complete history and physical that has been performed within 30 days prior to admission, so long as an examination for any changes in the patient's condition is completed and documented (interval note) in the medical record within twenty-four (24) hours after admission, but prior to surgery or a procedure requiring anesthesia services."
An interview was conducted with the Director of Patient Safety (DPS) on 11/4/13 at 11:25 A.M. The DPS stated that Patient 1's attending physician was currently in the process of dictating the History and Physical. That occurred seven days after Patient 1 was admitted to Hospital A. The DPS further explained that Patient 1's attending physician was not following the hospital's Medical Staff Bylaws regarding a History and Physical dictated or written for each patient within 24 hours of the patient's admission to the hospital.