HospitalInspections.org

Based on record review, staff interview, and policy review, the facility failed to maintain accurate documentation in the medical record. This affected one (Patient #2) of ten records reviewed.

Findings include:

Review of the medical record revealed Patient #2 presented the ER at the North campus on 01/12/24 at 11:07 PM with a chief complaint of dental pain and was discharged on 01/13/24 at 12:04 A.M.


Review of the medical record revealed Provider note dated 01/13/23 at 12:10 A.M., amended on 01/17/24 at 5:02 P.M. stated Patient #2 was requesting a topical medication for his left shoulder and later in the same note stated the patient had chronic right shoulder pain. The note had been amended on 02/27/2024 at 10:28 A.M. and in which details of left or right were omitted and referred to only as "shoulder pain".

Review of Patient Relations (PR) Worksheet revealed on 01/16/23 at 12:36 P.M. Patient #2 left a message that his care was atrocious, he had filed a complaint with the medical board, and he requested a return call. PR called back on 01/16/23 at 11:52 A.M. and the patient stated among other complaints that his medical record was "fabricated and stated he had chronic right shoulder pain when he had left shoulder pain from an accident.

On 01/26/24 at 10:27 A.M., Patient #2 called and left a message with PR requesting a return call. The PR rep returned a call on 01/26/24 at 11:40 A.M. and told Patient #2 the documentation of right versus left shoulder had been corrected.

On 02/08/24 at 8:53 A.M., the PR Manager documented the patient continued to call back on 02/06/24 and was upset the amendment to the medical record was still inaccurate and stated he had both re-requested an amendment in writing and had contacted the state. The patient complained the chart was updated previously indicating there were injuries to the left shoulder; however, in one sentence it was corrected to state left shoulder and in the following sentence it still stated right shoulder pain. PR confirmed the note in the record remained inaccurate, and the concerns were elevated for further review.

During an interview on 02/27/24 at 8:18 A.M. North ER Nurse Manager I stated she was aware the patient, very upset, had called within 24 hours of his ER visit and complained the PA had charted he had chronic right shoulder pain when it had actually been acute left shoulder pain. North ER Nurse Manager I stated the note had been corrected, then verified after looking at the amended note dated 01/13/23 at 12:10 A.M., amended on 01/17/24 at 5:02 P.M. was still inaccurate and contained references to both left and right shoulder pain. The Nurse Manager stated she had told the patient the note had been corrected without confirming for herself that it was correct.

Review of nine additional patient records revealed no concerns with accuracy of medical records.

Review of policy titled "Premier Health Information Management Services Amendments, addendums, and Corrections in EPIC Policy" dated 02/28/22 revealed medical records were corrected to ensure the integrity and accuracy of patient information.