HospitalInspections.org

Based on review of one of one applicable record reviewed it was determined that a verbal order was not authenticated by the person who wrote the order and the physician who gave the order.

Findings include:


1.) Review of the Patient's medical record dated 5/28/10 indicated a written order, dated and timed, however not authenticated and not signed by the ordering physician indicated laboratory blood tests, a cervical spine CT scan, a head CT scan and maxillofacial CT scans were ordered. However, the was no name to identify who wrote the verbal order and no practitioners name to identify who was the ordering practitioner.