HospitalInspections.org

Based on medical record review, interviews, and policy review, the facility failed to maintain complete medical records on three (#4, #5, and #6) patients of six patients reviewed.

The findings included:

Medical Record review revealed, patient #4 was admitted to the facility on August 3, 2010, with diagnoses of Abdominal Pain, Dizziness, Anemia, and Transient Ischemic Attack, and discharged from the facility on August 4, 2010. Further review of the medical record on September 27, 2010, revealed no discharge summary.

Medical Record review revealed patient #5 was admitted to the facility on August 10, 2010, and discharged on August 11, 2010. Further review of the medical record on September 27, 2010, revealed no discharge summary.

Medical record review revealed patient #6 was admitted to the facility on August 13, 2010, with diagnosis of Angina Pectoris, and was discharged on August 15, 2010. Further review of the medical record on September 27, 2010, revealed no discharge summary.

Interview with the risk manager on September 27, 2010, at 12:30 pm, confirmed there were no discharge summaries in the records of patients #4, #5, and #6.

Review of the facility's policy titled "Incomplete Medical Records" revealed "Medical records shall be completed promptly and authenticated or signed by a physician, dentist, or podiatrist within two (2) weeks following a patient's discharge." Further review of the policy revealed, "The records of discharged patients are completed within a period of time in no event exceeds 30 days following discharge".