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BETH ISRAEL DEACONESS HOSPITAL - PLYMOUTH
MEDICAL RECORD SERVICES
Tag No.: A0450
Based on documentation review it was determined the Hospital failed to ensure all medical record entries were legible, timed and authenticated in one of one applicable medical record reviewed.
Findings included:
GI progress notes written on June 12, 13, 14 and 15, 2010 and special procedure notes written on June 14, 2010 and an additional special procedure note, which was undated were illegible.
GI progress notes written on June 12, 13, 14,15, and 16, 2010 and a surgery note written on June 17, 2010 did not include a time to indicate when the note was written.
A GI progress note written on June13, 2010 did not include a signature to establish the identity of the author.