HospitalInspections.org

Based on medical record review and personnel interview, the facility failed to ensure a nurses' note stating the lab specimen had been sent to lab was in the medical record for 2 of 4 (N1 and N3) closed patient medical records reviewed of a patient who had an order for testing of a urine specimen.

Findings:
1. Review of closed patient medical records on 7/9/12 at 12:50 PM indicated:
A. Patient N1 presented to the ED on 3/8/12 at 14:52 PM for chief complaint of abdominal pain. Per ED Progress Notes dated 3/8/12:
a. a urinalysis was ordered at 16:19 PM and results received at 17:48 PM.
b. lacked documentation in the medical record that this specimen was sent to the lab.

B. Patient N3 presented to the ED on 3/8/12 at 12:37 PM for chief complaint of abdominal pain. Per ED Progress Notes dated 3/8/12:
a. a urinalysis was ordered at 13:36 PM and results received at 14:00 PM.
b. lacked documentation in the medical record that this specimen was sent to the lab.

3. Personnel P2 was interviewed on 7/9/12 at approximately 12:46 PM and confirmed, the protocol for females presenting with abdominal pain requires them to provide a urine specimen upon arrival. Although the above-mentioned patients provided a urine specimen and the test was completed by laboratory personnel, the medical record lacked documentation that the specimen was sent to the lab. Normally, it is an expectation, not a written protocol, that it is documented in the patient's medical record that the specimen is sent to lab.