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Based on clinical record review, job description review and interview, it was determined one of one (#1) Licensed Practical Nurse (LPN) Medical Scribe wrote the assessment and plan of care on 2 (#8 and #10) of 10 (#1-#10) patients without evidence one of one (#2) physician was in the presence of the scribe, reviewed the scribes documentation for accuracy and signed and dated the encounter upon completion. The failed practice did not ensure the physician's input on the assessment and plan of care and had the potential to affect all patients seen by the LPN Medical Scribe. The findings follow:

A. Review of the LPN Medical Scribe Job Description on 06/29/16 revealed the following:
1) "Job Summary: The purpose of this position is to handle time-consuming clerical responsibilities for physicians during patient encounters. Scribes accompany a physician and directly observe patient encounters. This position accurately documents the events and decision-making in a manner that results in appropriate medical charting. The Medical Scribe also completes clerical activities necessary to assist with processing of physician orders for tests and medications. By accomplishing the time-consuming clerical duties that otherwise would be assigned to a physician, Scribes enable physicians to spend more time with individual patients and increase the overall flow of patients in the department.
2) Essential Duties and Responsibilities include the following. Other duties or task may be requested or assigned by immediate supervisor, his/her designee, or other management/supervisor.
a) Accurate, timely charting of patient encounters to include, but not limited to, patient history, physical exams, diagnostic findings, lab and test results, consultations with other providers, diagnoses, discharge instructions and prescriptions.
b) Scribes accompany the physician upon patient interview and examination.
c) Scribes document the physician dictated patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications and allergies.
d) Scribes document physical examination findings and procedures as performed by the physician.
e) Scribes document the results of laboratory and radiographic studies as dictated by the physician.
f) Scribes document the correct time of patient care related activities, including physician to physician communication, family communication and re-examination of the patient.
g) When the physician concludes the patient's encounter, the physician will review all documentation completed by the Scribe, make any necessary amendments, and sign the chart. The physician is ultimately responsible for documentation of the patient's encounter.
h) The physician and the Scribe will make 'chart rounds' to review patient status, delays and any other care-related issues."

B. In an interview Physician #1 on 06/29/16 at 1545, he confirmed the LPN Medical Scribe Job Description did not specify a time frame the physician should sign the assessment and plan of care after the LPN Medical Scribe transcribed the information.

C. Review of Patient #8's clinical record on 06/29/16 revealed one of one Adult Progress Note dated and signed by LPN #1 on 06/28/16 at 1439 and Physician #2 on 06/29/16 at 1237. It could not be determined by the time frame of the signatures if Physician #2 was present when LPN #1 gathered the information for the assessment and plan of care for Patient #8 or if LPN #1 performed the assessment and formulated plan of care. The findings were confirmed in an interview with the Chief Nursing Officer and the Director of Quality/Risk Management on 06/19/16 at 1545.

D. Review of Patient #10's clinical record on 06/29/16 revealed one of one Adult Progress Note dated and signed by LPN #1 on 06/28/16 at 1441 and Physician #2 on 06/29/16 at 1237. It could not be determined by the time frame of the signatures if Physician #2 was present when LPN #1 gathered the information for the assessment and plan of care for Patient #10 or if LPN #1 performed the assessment and formulated plan of care. The findings were confirmed in an interview with the Chief Nursing Officer and the Director of Quality/Risk Management on 06/19/16 at 1555.