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Based on review of medical staff bylaws, review of medical records, and interview with staff, the hospital failed to ensure that medical records were complete prior to filing.

Finding include:

Cross Refer to A0450. The facility failed to ensure all reports are signed prior to the filing of medical records as being complete.

Based on review of medical staff bylaws, review of medical records, and interview with staff, the hospital failed to ensure that x-ray reports were authenticated promptly by the radiologist reading the x-ray.

Findings include:

Eighteen medical records were selected at random from a list of discharges from November, December and January and reviewed along with 3 inpatient medical records.

Sixteen medical records of the 21 records reviewed contained x-ray reports. Of the 16 records with x-ray reports, 11 records were found to have x-ray reports that had not been electronically signed by the radiologist. Nine of these records had been filed as complete medical records with the unsigned x-ray reports.

Based on review of medical staff bylaws and review of medical records, the hospital failed to ensure that all inpatient medical records contained a history and physical examination.

Findings include:

1. Medical staff rules and regulations require that a complete history and physical examination is documented by the attending physician within 24 hours of admission.

2. On 02-23-10, at 3:30 p.m., inpatient hospital medical records were reviewed.
The history and physical examination was absent on 1 of 3 inpatient records.
The medical record belonged to a patient admitted on 02-19-10.

Based on review of medical staff bylaws, review of medical records, and interview with staff, the hospital failed to ensure that all discharge records were complete within 30 days of discharge.

Findings include:

On 02-24-10, a count of medical records in the physicians ' incomplete files was made.

There were approximately 67 medical records delinquent over 30 days. These records dated back to September, 2009, with several records dating back to 2008. Thirty nine of these delinquent records belonged to one physician.

Based on document review, the above facility failed to complete a post anesthesia evaluation with in 48 hours in 5 of 12 patients reviewed.
Findings:
1. In 5 of 12 surgical records reviewed, there was no dated, timed, and signed post anesthesia evaluations within 48 hours.
2. In three of these charts there was not applicable in the post anesthesia evaluation slot. The records were reviewed to be sure post anesthesia was not documented in another place.
3. Medical Record employee was asked and could not show where it was documented. She later on 02-24-10 at 11:00 am came in and stated the anesthesiologist stated she documented post anesthesia assessment of the front of the form. The charts were checked and it was not there.
4. This finding was presented at exit and no additional information was provided.