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LEWISGALE HOSPITAL MONTGOMERY
MEDICAL RECORD SERVICES
Tag No.: A0450
Based on interviews, facility document and medical record reviews, the facility failed to interpret the results of performed test and/or procedure per facility policy.
The findings include:
On August 5, 2024 a review of Patient #1's medical record was conducted with Staff Member #2.
The facility received an order for Patient #1 dated October 25, 2023 for an electrocardiogram (EKG), and other tests. The EKG was performed on October 31, 2023 at 10:16 AM and the result was electronically signed by a physician on November 7, 2023 at 7:42 AM.
The facility received an order for Patient #1 with a handwritten date of July 3, 2024 for another EKG. The EKG was performed on July 8, 2024 at 9:32 AM and the result was electronically signed by a physician on July 13, 2024 at 9:44 PM.
A review of the facility's policy "Cardiology Procedure Timeliness Policy", effective 3/2022, revealed in part "...Routine Tests...Any routine diagnostic test ordered. This includes but is not limited to...EKGs...Goal: Interpretation and dictation of routine test results will occur within 48 hours of test completion...".
The findings were discussed with Staff Members #1, #2, #7, #8 and #9 at the exit conference on August 6, 2024 at 9:15 AM.