HospitalInspections.org

Based on review of the policy and procedure manual for the medical record department, the hospital failed to ensure that the medical record department was operating with current policies and procedures addressing all aspects of the service.


Findings include:


Review of the policy and procedure manual for the medical record department revealed that the last documented review of the medical record department's policy and procedure manual was in 2006.

Based on review of the Medical Staff's Rules and Regulations and review of medical records, the hospital failed to ensure that all entries in t22 of 22 medical records reviewed had been timed.


Findings include:


1. 14 medical records were selected at random from a list of discharges from August, 2011, through January, 2012, and reviewed along with eight (8) current inpatient medical records for a total 22 medical records.


2. On 10 of 22 medical records reviewed, all progress notes had not been timed when written.


3. On 21 of 22 medical records reviewed, the handwritten history and physical examination had not been timed by the physician when he dated the history and physical.


4. On 12 of 14 discharged medical records reviewed, the dictated discharge summary had not been timed as to the time of dictation or the time that the discharge summary had been transcribed.

Based on policy and procedure review and staff interview, the facility failed to ensure that pharmacy policies and procedures were periodically reviewed and revised.


Findings include:


Review of the Pharmacy Procedure Manual revealed no documented evidence that pharmacy policies were periodically reviewed and revised. This finding was discussed during an interview with the Pharmacy Director February 21, 2012 from 11:00 a.m. to 11:05 a.m. At that time she did not disagree with this finding.