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ASCENSION ST VINCENT HOSPITAL
MEDICAL RECORD SERVICES
Tag No.: A0450
Based on document review and interview, the facility failed to ensure all patient medical record entries are signed for 2 of 3 (P#1, P#2) patient medical records reviewed.
Findings included:
1. Review of patient medical records on 5-9-12 lacked evidence that 2 of 3 (P#1, P#2) patient medical record entries were signed on the Pre-Procedure Record.
2. Review of facility policy titled MEDICAL RECORD REQUIREMENTS #86902 on 5-9-12 indicates the following: All medical record entries must be signed
3. Interview with B#10 on 5-9-12 at 1555 hours confirmed that the Pre-Procedure Record for P#1 was not signed by the person entering the information; B#10 confirmed all medical record entries are to be signed by the author.
4. Interview with B#9 on 5-9-12 at 1540 hours confirmed that the Pre-Procedure Record for P#2 was not signed by the person entering the information; B#9 confirmed all medical record entries are to be signed by the author.