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Based on interview and record review, the facility failed to ensure that Patient 1's medical record was complete, dated, and timed.

Findings:

Patient 1's medical record was reviewed on 1/13/10. Patient 1 was at the facility from 12/31/09 - 1/5/09. Patient 1 had been admitted for an operation to have her abdominal wall hernia repaired. The medical record contained the following documents that were not completed:
1. The physician's signature on the Pre-Op Admission Orders dated 12/30/09, were not timed and the patient's height and weight were blank.

2. The following areas on Patient 1's History and Physical dated 12/31/09 at 12 noon, were blank:
a. Past Medical History
b. Past Surgical History
c. Family History
d. Social History
e. Genitourinary (urinary) system
f. Musculoskeletal system (muscles and skeletal)
g. Skin/ lymphatic system
h. date of birth
i. date and time
j. Medication/ dose/ Schedule
k. Laboratory/Radiologic Data

3. Three Anesthesia records for Patient 1 dated 12/31/09, 1/2/10, and 1/4/10, were dated but not timed.

4. Patient 1's Anesthesia Evaluation Form, contained two Anesthesiologist signatures, dated 1/4/10 and 1/5/10, were not timed. The space at the top of the form for the "Date of Surgery," was blank.

5. The preoperative outcomes for Patient 1's nursing diagnoses were left blank on the Perioperative Record dated, 12/31/09.

During an interview with Admin A on 1/15/10, he verified that Patient 1's Operating Room record was not complete. The outcomes for the nursing diagnoses were not documented.

On 2/26/10 at 1:53 pm, Administrative Staff C acknowledged there were incomplete documentation in Patient 1's clinical record.

On 1/15/10, a facility policy and procedure titled, "Accessory Document to the Medical Staff Bylaws, Rules and Regulations of the Medical Staff", Edition: September 2009, was reviewed. The facility's policy indicated that all patient medical records must be legible, complete, dated, and timed.

Based on interview and record review, the facility failed to implement their policy and procedure when a complete medical history was not preformed on Patient 1 prior to surgery.

Findings:

Patient 1's medical record was reviewed on 1/13/10. Patient 1 was admitted on 12/31/09, for a same day surgical procedure to repair an abdominal wall hernia. The History and Physical report found in Patient 1's medical record was blank in the following fields:

a. Past Medical History
b. Past Surgical History
c. Family History
d. Social History
e. Review of the genitourinary (urinary tract) field
f. Musculoskeletal (muscles and skeleton),
g. Review of the skin/ lymphatic system
h. Medications, laboratory, and X-ray data were also blank.

Anesthesia's preoperative assessment for Patient 1, dated 12/31/09, classified Patient 1 as having an ASA score of 3 (American Society for Anesthesiologists' system for determining a patient's health fitness before surgery). ASA 3 is a patient with severe systemic disease (disease that involves the whole body rather than a part of the body).

A facility policy and procedure titled, "History and Physicals", with a revision date of 9/07, indicated that patients with an ASA score of 3 or above will have a complete medical history taken. A completed history and physical shall contain at a minimum...history of present illness, an age appropriate family and social history, past medical and surgical history, current medications, allergies, and a review of the patient's systems.

During an interview with Administrative Staff C on 2/18/10 at 3 pm, she verified that the abbreviated history and physical performed on Patient 1 was not appropriate.