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BRIGHAM AND WOMEN'S HOSPITAL
MEDICAL RECORD SERVICES
Tag No.: A0450
Based on the review of 11 ED medical records, it was determined medical record entries were not timed in accordance with ED Policy in 4 of 8 applicable medical records.
Findings included:
The ED Policy titled "Documentation" indicated the ED Physician Record must include the time at which the patient-physician encounter took place.
Physician documentation in the following ED patient's medical records did not include the time of the patient-physician encounter/physician evaluation of the patient:
Patient #2; ED visit commencing at 5:36 PM on 3/12/11.
Patient #3; ED visit commencing at 6:26 PM on 3/16/11.
Patient #7; ED visit commencing at 12:03 AM on 3/11/11.
Patient #11; ED visit commencing at 1:47 PM on 3/2/11.