HospitalInspections.org

Based on clinical record review and interview it was determined that nine (#1, #3-10) of ten (#1-10) clinical records contained operative reports that did not contain the time of surgery. Failure to include the time of surgery did not allow knowledge of which surgical procedure was performed in what order in the event of multiple surgeries in one day. Findings follow:

A. Review of the operative reports for nine (#1, #3-10) of ten (#1 - 10) patients revealed the operative reports did not contain the time the surgical procedure was performed.
B. The above findings were verified by the Administrative Director and the Interim OR Manager at 1040 on 04/17/12.





Based on clinical record review and interview it was determined one (#2) of ten (#1-10) did not contain an operative report. Failure to include an operative report did not allow accurate recording of the surgical procedure. The failed practice affected one (#2) of ten (#1 - 10)patients on 04/16/12. Findings follow:

A. Review of the clinical record for one (#2) of ten (#1 - 10) patients revealed the clinical record did not contain an operative report.
B. The above findings were verified by the Administrative Director and the Interim OR Manager at 1040 on 04/17/12.