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EMANUEL MEDICAL CENTER
MEDICAL STAFF RESPONSIBILITIES - UPDATE
Tag No.: A0359
Based on review of medical records, Medical Staff Bylaws, policies and procedures, and staff interview, it was determined that the facility failed to ensure that history and physical examinations (H&P) were completed within 24 hours of admission for six (6) of ten (10) medical records reviewed (#s 1, 2, 3, 5, 7, and 9).
Findings:
Review of medical record revealed the following:
Patient #1 was admitted on 03/21/16 at 3:30 a.m. and the H&P was dated 03/22/16 at 10:12 a.m.;
Patient #2 was admitted on 03/18/16 at 6:00 a.m. and the H&P was dated 03/23/16 at 12:52 p.m.;
Patient #3 was admitted on 03/11/16 at 3:30 a.m. and the H&P was dated 03/22/16 at 10:37 a.m.;
Patient #5 was admitted on 07/21/16 at 9:00 a.m. and the H&P was dated 07/22/16 at 4:22 p.m.;
Patient #7 was admitted on 07/25/16 at 11:16 a.m. and the H&P was dated 07/26/16 at 4:01 p.m.; and
Patient #9 was admitted on 07/20/16 at 2:50 p.m. and the H&P was dated 07/21/16 at 5:31 p.m.
Review of the Medical Staff Bylaws, Rules and Regulations, Reviewed and approved 02/23/16 revealed in the Medical Records section that a complete admission history was to be dictated within 24 hours of admission.
Review of facility policy entitled Interdisciplinary Assessment Overview, policy number 03.002, last revised 02/2014, required the Medical History and physical Examination and Psychiatric Evaluation - Comprehensive Psychiatric Evaluation to be completed and placed on the patient's chart within 24 hours of admission.
During an interview with the Behavioral Health Unit's Clinical Coordinator (BHUCC - employee #10) on 07/27/16 at 10:00 a.m. in the Private Dining Room, the BHUCC confirmed that the electronic date and time on the H&Ps for patients #1, 2, 3, 5, 7, and 9 was not within 24 hours of the patients admissions.
CONTENT OF RECORD: HISTORY & PHYSICAL
Tag No.: A0458
Based on review of medical records, Medical Staff Bylaws, policies and procedures, and staff interview, it was determined that the facility failed to ensure that history and physical examinations (H&P) were completed within 24 hours of admission for six (6) of ten (10) medical records reviewed (#s 1, 2, 3, 5, 7, and 9).
Findings:
Review of medical record revealed the following:
Patient #1 was admitted on 03/21/16 at 3:30 a.m. and the H&P was dated 03/22/16 at 10:12 a.m.;
Patient #2 was admitted on 03/18/16 at 6:00 a.m. and the H&P was dated 03/23/16 at 12:52 p.m.;
Patient #3 was admitted on 03/11/16 at 3:30 a.m. and the H&P was dated 03/22/16 at 10:37 a.m.;
Patient #5 was admitted on 07/21/16 at 9:00 a.m. and the H&P was dated 07/22/16 at 4:22 p.m.;
Patient #7 was admitted on 07/25/16 at 11:16 a.m. and the H&P was dated 07/26/16 at 4:01 p.m.; and
Patient #9 was admitted on 07/20/16 at 2:50 p.m. and the H&P was dated 07/21/16 at 5:31 p.m.
Review of the Medical Staff Bylaws, Rules and Regulations, Reviewed and approved 02/23/16 revealed in the Medical Records section that a complete admission history was to be dictated within 24 hours of admission.
Review of facility policy entitled Interdisciplinary Assessment Overview, policy number 03.002, last revised 02/2014, required the Medical History and physical Examination and Psychiatric Evaluation - Comprehensive Psychiatric Evaluation to be completed and placed on the patient's chart within 24 hours of admission.
During an interview with the Behavioral Health Unit's Clinical Coordinator (BHUCC - employee #10) on 07/27/16 at 10:00 a.m. in the Private Dining Room, the BHUCC confirmed that the electronic date and time on the H&Ps for patients #1, 2, 3, 5, 7, and 9 was not within 24 hours of the patients admissions.