HospitalInspections.org

Based on record review and interview the facility failed to ensure authentication of informed consent forms in 6 of 10 patient records reviewed (#1, #2, #5, #6, #7, #8).

Findings:

Facility policy #03294 "Medical Records Documentation Requirements", reviewed on 1/13/2014 at 9:20 a.m., states in part "I. Procedure...3. All entries to the medical record must be dated, timed and signed."

Pt. #1's MR, reviewed 1/13/2015 at 10:25 a.m., contains a surgical consent form dated 12/11/2013. Signatures for the patient, doctor and witness are untimed.

Pt. #2's MR, reviewed 1/13/2015 at 10:08 a.m., contains a surgical consent form with signatures for the patient, doctor and witness. The signatures are not dated or timed.

Pt. #5's MR, reviewed 1/13/2015 at 10:35 a.m., contains a surgical consent form with untimed signatures for the doctor and witness.

Pt. #6's MR, reviewed 1/13/2015 at 10:45 a.m., contains a surgical consent form with an untimed doctor signature.

Pt. #8's MR, reviewed 1/13/2015 at 10:50 a.m., contains an outpatient registration agreement with an untimed patient signature and no witness signature.

Pt. #9's MR, reviewed 1/13/2015 at 10:55 a.m., contains a surgical consent form with an undated and untimed doctor signature.

All findings were verified at the time of the review with Manager B and VP C. On 1/13/2015 at 11:25 a.m., VP C stated the consent forms should include signatures that are dated and timed.