HospitalInspections.org

Based on medical record review, policy and procedure review, Medical Staff Rules and Regulations review the hospital:
1. failed to ensure that it has policies and procedures that address appropriate security safeguards as related to employee use of the electronic medical record system, precautions taken to prevent unauthorized persons from accessing the electronic medical records system, and the sanctions taken for inappropriate use of the electronic medical record by employees.
2. failed to ensure that all entries in the medical record are timed.



Findings include:


There were no policies and procedures available for review pertaining to the use of the electronic medical record system, addressing security, precautions, and sanctions to be taken by the facility.


10 medical records were selected at random from a list of recent discharges and reviewed along with 12 inpatient medical records for a total of 22 medical records. Six (6) of 22 medical record's handwritten history and physical exams were scanned into the medical record. These history and physical exams were dated, but had not been timed by the practitioner performing the exams.

Based on review of Medical Staff Rules and Regulations, medical record review, and hospital policy and procedure review, the facility failed to ensure that verbal orders are signed by the physician within 48 hours.


Findings include:


10 medical records were selected at random from a list of recent discharges and reviewed along with 12 inpatient medical records for a total of 22 medical records. Eight (8) of the 12 inpatient medical records reviewed had physician's orders that had not been signed within 48 hours by the responsible physician.

Based on review of Medical Staff Rules and Regulations, medical record review and hospital policy and procedure review, the facility failed to ensure that a history and physical examination is documented in the medical record within 24 hours of admission.


Findings include:


10 medical records were selected at random from a list of recent discharges and reviewed along with 12 inpatient medical records for a total of 22 medical records. On two (2) of the 12 inpatient medical records reviewed, a history and physical exam had not been documented in the medical record within 24 hours of admission. On five (5) of the 12 inpatient medical records reviewed, a physical exam had not been documented in the medical record within 24 hours of admission.