HospitalInspections.org

Based on interview, document and record review Hospital A failed to ensure that 1 of 48 sampled patient's (Patient 20) medical record contained an adequate and complete History and Physical.

Findings:

Patient 20 was admitted to Hospital A on 4/24/12 with a diagnosis of recurrent syncope (temporary loss of consciousness caused by a fall in blood pressure) according to the Admission Facesheet. A review of Patient 20's medical record was conducted on 4/25/12 at 9:30 A.M. According to an Operative Report, dated 4/24/12, Patient 20 underwent a cardiac catheterization and implantation of a loop recorder (an implantable patient activated heart monitoring system).

A review of the hospital's policy and procedure entitled "Physician Documentation Requirements", dated 1/12, indicated that "A medical history and physical should consist of, however is not limited to : the patient's chief complaint, History of Present Illness, Past Medical History, any prior surgeries, OB/GYN history. Allergies, Current Medications, ETOH/Smoking History, Exercise/Functional level, Occupational and Environmental History, Social History, Family History, Review of Systems, Physical Examination, Lab results, Assessment and Plan...There must be a complete medical history and physical performed no more than 30 days before or 24 hours after admission for each patient by a physician..."

On 4/25/12 at 10:10 A.M. a concurrent interview and review of Patient 20's History and Physical was conducted with the Medical Director of Quality (MDQ 1). After review of the patient's History and Physical, dated 4/23/12, MDQ 1 acknowledged that Patient 20's History and Physical was not adequate for a patient having a procedure with anesthesia. MDQ 1 stated that the History and Physical was incomplete because it did not contain an examination of the patient's heart and lungs or documentation of the condition of the patient's airway. Also, there was no mention of the patient's allergies or functional level. There was no review of systems and the physical examination was lacking completion and was not consistent with what was documented regarding Patient 20 elsewhere in the chart such as no mention of the patient's previous cerebral vascular accident (stroke) or her severe expressive aphasia (expression by speech or writing is severely impaired).