HospitalInspections.org

Based on medical record and policy review as well as interview it was determined that the nursing staff failed to assure a complete and accurate medical record for Patient #6 as evidenced by the nursing staff ' s failure to document patient education in the Emergency Department Medical Record.

The findings include:

Howard University Hospital Administrative Standard Practice Manual Policy HIM-74-ASP entitled Uniform Documentation of Medical Record, last reviewed and revised April 2010 was reviewed.

Within the Policy statement, Sub-section I refers to Medical Record Content and Item A, regarding general requirements for all medical records further stipulates " ...35. Patient ' s learning needs, abilities, preferences, and readiness to learn; ... 37. When appropriate, that the patient was educated about ... the safe and effective use of medical equipment ... "

A telephone interview was conducted with a staff nurse and the Assistant Nurse Manager of the Emergency Department on November 20, 2013 at approximately 11:46AM. The nurses stated the expectation of the nursing staff with regard to documentation is that patient education must be documented. The nurses acknowledged that the record lacked documented evidence of patient education.

Patient #6 presented to the Emergency Department on January 30, 2013 with complaints of Shortness of Breath and Abdominal Pain.

Review of Patient#6 ' s ED record revealed the nursing staff failed to document information regarding Patient #6 ' s learning needs, abilities, preferences, and readiness to learn;, as well as that Patient #6 was educated about medications, procedures, diagnoses and treatments, and plan of care.

The nursing staff failed to assure a complete and accurate medical record for Patient #6.