HospitalInspections.org

Based on documentation in 15 of 29 clinical records reviewed (#s 13, 15, 17 through 29) it was determined that the hospital failed to ensure that all entries in the clinical records were dated and/or timed, and/or authenticated in accordance with the hospital's own requirements. Findings include:

1. Review of the Rules and Regulations for the Professional Staff of the hospital dated 8/17/06 revealed a requirement at section VI. Medical Records that "All clinical entries in the patient's medical record shall be dated, timed, and properly authenticated by the individuals making them." Additionally, a requirement at section V. Orders was that "The person initiating a verbal order shall make all reasonable efforts to sign it within twenty-four (24) hours after it is given."

2. Record #13 - The obstetric discharge summary was not dated and timed.

3. Record #17 - The physical therapy treatment plan and daily documentation form was not dated and timed;
Multiple entries on the rehab therapy services form were not timed;
The swing bed physician's admission orders were not timed.

4. Record #20 - Physician progress notes dated 4/15/10 were not timed;
Written physician's orders which began with "NPO, full code..." were not dated and timed;
The Adult Medical Venous Thromboembolism Prophylaxis Order Form dated 4/15/10 was not timed;
The Informed Consent For Transfusion of Blood or Blood Products dated 4/15/10 was not timed, and the physician's authentication per electronic signature was not completed until 4/28/10.

5. Record 21 - Physician progress notes dated 2/10, 2/22, 2/26, and 3/2/10 were not timed;
The Operative Note dated 2/7/10 was not timed;
Written physician's orders dated 2/26/10 were not timed;
Verbal orders dated 2/7/10 were not timed, and the physician's authentication per electronic signature was not completed until 4/3/10;
Restraint Orders Physician Progress Notes dated 2/10/10 were not authenticated by the physician until completed per electronic signature on 4/3/10;
Written physician's orders which began with "D/C phenergan..." were not dated, timed, or authenticated by the physician until completed per electronic signature on 4/17/10;
A Blood Bank Requisition Transfusion Record for a transfusion which was started on 2/18/10 did not include the date, time, and authentication by the individual who "Stopped" the transfusion.

6. Record 22 - The entries on the Emergency Physician Record were not dated and timed.

7. Record 23 - The Insulin Protocol for Type II Diabetics Order form was dated either 3/1/10 or 4/1/10 and was not timed;
Blood Bank Requisition Transfusion Records for two transfusions which were started on 4/2/10 were not authenticated by the individual(s) who "Started" and "Stopped" the transfusions;
The Informed Consent For Transfusion of Blood or Blood Products was not dated, timed, authenticated by the witness, and the physician's authentication per electronic signature was not completed until 4/7/10.

8. Record 27 - Written physician's orders which began with "NPO..." were not dated and timed;
A physician's verbal order dated 4/2/10 was not authenticated by the physician until completed per electronic signature on 4/20/10.

9. Record 29 - A physician's progress note which began "CC:..leg pain..." was not dated and timed;
The Insulin Protocol for Type II Diabetics Order form dated 4/6/10 was not timed;
The Adult Medical Venous Thromboembolism Prophylaxis Order Form dated 4/6/10 was not timed;
Radiology consent forms were not dated, timed, or authenticated by the witness.

10. Similar findings were identified in record #s 15, 18, 19, 24, 25, 26, and 28.