HospitalInspections.org

Based on medical record review, staff interview, and policy review, the medical staff failed to complete an outpatient medical visit note for one (1) of eleven patients (Patient #38).

Findings include :

A review of the hospital's " Bylaws of the Medical Staff" revised 08/07/2020 showed " Article XI: Policies of The Medical Staff Part A. Purpose of Policies Medical Staff policies and procedures as may be necessary to implement the general principles of conduct found in these Bylaws more specifically shall be adopted in accordance with this Article. Policies and Procedures shall set standards of practice that are to be required of each individual exercising clinical privileges in the Hospital and shall act as an aid to evaluating performance under, and compliance with, these standards. Policies and Procedures shall have the same force and effect as the Bylaws..."

Review of the hospital's policy titled "Medical Staff Policies and Procedures" revised 09/13/2017 showed "Chapter 6: Medical Records ...A. General Rules; An adequate medical record shall be maintained for each patient who is evaluated and/or treated at this Hospital as an inpatient or ambulatory patient ... I. Ambulatory Medical Records; A medical record shall be maintained for every patient receiving ambulatory care services within the Hospital, Primary Care Centers, Regional Outpatient Centers or other satellite facilities or from a [Hospital Named]-employed licensed independent practitioner providing consultative services at another facility. The ambulatory record shall contain sufficient information to document the care given, procedures performed and level of services rendered to the patient. The ambulatory medical record shall contain, where appropriate:...2. date of ambulatory care and discharge;3. relevant history of the illness or injury and physical findings;4. diagnostic and therapeutic orders; 5. clinical observations, including results of treatment, where appropriate; 6. reports of procedures, test and results, where appropriate; 7. diagnostic impressions;8. patient disposition and any pertinent instructions given to the patient or the patient's parent(s) or legal guardian for follow-up care; 9. immunization history, where appropriate; 10. allergy history, including drug allergy, if any; 11. adverse drug reactions, if any; 12. medication reconciliation;13. pain assessment;14. safety assessment;15. informed consent, where appropriate; 16. growth chart, where appropriate;17. consultation reports, where appropriate;18. referral information to and from outside agencies as appropriate; and19. patient summary list. At the time of each ambulatory care visit, the licensed independent practitioner shall record on the ambulatory treatment record pertinent clinical observations, relevant patient history, treatment rendered, and follow-up care recommended ...Transcribed documents or reports of an ambulatory encounter shall be completed and authenticated within 30 days of the encounter.

The surveyor reviewed the medical record for Patient #38 on 06/26/2024 at approximately 11:00 AM with Employee # 31, Gastroenterology, Hepatology and Nutrition Outpatient Clinic Manager. According to the medical record Patient #38 arrived at their scheduled appointment on 03/21/2024 at approximately 2:10 PM. However, the record lacked documentation of the ambulatory care and discharge follow up, per hospital policy.

The surveyor conducted an interview with Employee #31 on 06/26/2024 at approximately 11:30 AM. Employee #31 confirmed Patient #38 was seen by a physician on 03/21/2024 however there was no documentation of the encounter.