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ASPIRE HEALTH PARTNERS
CONTENT OF RECORD: ORDERS,NOTES,REPORTS
Tag No.: A0467
Based on record review and interview, the facility failed to maintain a current and complete medical record for every patient seeking care for 3 of 5 sampled patients (#1, 2 & 3).
Findings:
1. Review of patient #1's record failed to specify on the admission Routine Standing Lab orders, and on post admission orders, it failed to specify Special Precautions or cognitive learning.
2. Review of patient #2's record failed to specify on the admission orders a Diet Order or Routine Standing Labs.
3. Review of patient #3's record failed to specify on the admission orders special precautions or cognitive learning.
Interview with the Risk Manager on 06/08/2010 at 1:30 p.m. confirmed the findings.