HospitalInspections.org

Based on review of one out of fourteen open medical records, it was determined that the medical record content (signature) illegibility and correction of errors was performed improperly.
Patient #7 is a 61 year old female admitted on 06/24/13 for an abdominal mass with subsequent surgical intervention. On review of Patient #1 ' s medical record, specifically, the " Transfusion Service Record " , it was determined that in 7 of 7 of the transfusion verification forms the signatures of the person initiating the transfusion as well as the co-verifier ' s signatures are illegible.
In addition, on further review of the " Transfusion Service Records " it was determined that in 6 of the 7 forms, the original clock number (used to identify the person documenting) had been obliterated by scratching out the documentation The acceptable standard of practice requires the writer to cross through the error with one line, write the word error, initial the error, and then make the necessary corrections.