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AURORA ST LUKES MEDICAL CENTER
MEDICAL RECORD SERVICES
Tag No.: A0450
Based on record review and interview, the hospital failed to complete 1 of 11 surgical consents (Patient #7) in a total of 11 medical records reviewed.
Findings include:
Review of policy "Informed Consent-Informed Refusal" #189 dated 8/30/2009 last reviewed 5/30/2017 page 8 of 19 under #3 Completing a Consent Form, "the Consent Form must be completed in its entirety".
Patient #7's medical record was reviewed on 9/05/18 at 11:35 AM with Clinical Informatics Educator L. Review of the surgical consent on Patient #7 revealed blank date lines next to Patient #7 and Spanish Interpreter M signatures and no times documented on the consent.
During 9/05/18 at 12:30 PM during an interview, Clinical Nurse Specialist U stated the date and times are required on the consent form, "they should have been filled in."