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SOUTH BALDWIN REGIONAL MEDICAL CENTER
CONTENT OF RECORD: ORDERS DATED & SIGNED
Tag No.: A0454
Based on medical record review and interview, the physicians failed to date and/or time orders for Patient Identifier (PI) # 1, PI # 2, PI # 3 and PI # 4. This deficient practice affected four of ten outpatient surgery medical records that were reviewed.
Findings include:
1). PI # 1 was admitted on 12/17/14 for outpatient surgery. A review of the medical record revealed the Pre-Admission orders and the Post-Operative orders were not dated or timed by the physicians. The Intra-Operative Standing Orders were not timed by the physician.
2). PI # 2 was admitted on 1/19/15 for outpatient surgery. A review of the medical record revealed the Pre-Admission orders and the Intra-Operative Standing Orders were not dated or timed by the physicians.
3). PI # 3 was admitted on 12/17/15 for outpatient surgery. A review of PI # 3's medical record revealed the Post-Operative orders were not dated or timed by the physician.
4). PI # 4 was admitted for outpatient surgery on 1/20/15. A review of PI # 4's medical record revealed the Intra-Operative Standing Orders were not timed by the physician. The Post-Operative orders were not signed or timed by the physician.
During an interview with Employee Identifier (EI) # 1, the Quality Manager confirmed the four medical records noted above were lacking times and/or dates for physician orders.
CONTENT OF RECORD: ORDERS DATED & SIGNED
Tag No.: A0454
Based on medical record review and interview, the physicians failed to date and/or time orders for Patient Identifier (PI) # 1, PI # 2, PI # 3 and PI # 4. This deficient practice affected four of ten outpatient surgery medical records that were reviewed.
Findings include:
1). PI # 1 was admitted on 12/17/14 for outpatient surgery. A review of the medical record revealed the Pre-Admission orders and the Post-Operative orders were not dated or timed by the physicians. The Intra-Operative Standing Orders were not timed by the physician.
2). PI # 2 was admitted on 1/19/15 for outpatient surgery. A review of the medical record revealed the Pre-Admission orders and the Intra-Operative Standing Orders were not dated or timed by the physicians.
3). PI # 3 was admitted on 12/17/15 for outpatient surgery. A review of PI # 3's medical record revealed the Post-Operative orders were not dated or timed by the physician.
4). PI # 4 was admitted for outpatient surgery on 1/20/15. A review of PI # 4's medical record revealed the Intra-Operative Standing Orders were not timed by the physician. The Post-Operative orders were not signed or timed by the physician.
During an interview with Employee Identifier (EI) # 1, the Quality Manager confirmed the four medical records noted above were lacking times and/or dates for physician orders.