HospitalInspections.org

Based on interview and record review, the hospital failed to ensure an interval updated History and Physical (H&P) exam was completed within 24 hours of admission prior to a surgical procedure per the hospital's policy, for 1 of 32 sampled patients (31).
As a result, there was potential for Patient 31's medical information to be inaccurate.

Findings:

1. Patient 31 was admitted to the hospital on 12/2/16 for cesarean section (surgery to deliver a baby) and sterilization procedure, per the Face Sheet.

On 1/18/17 at 14:05 P.M., a review of Patient 31's electronic medical record was conducted with the Director of Peri-Operative Services (LN 1). The H&P was dated 11/30/16. The Operative Report (a detailed account of the cesarean section surgery) was dated 12/2/16, two days after the H&P. There was no interval admission note in Patient 31's electronic medical record.

In a subsequent interview with LN 1, she confirmed an interval admission note was not included in Patient 31's medical record and added, "The pre-operative nurse was responsible for confirming an interval admission note was included when the H&P was older than 24 hours."

According to the hospital's policy and procedure, History and Physical Examination & Discharge Summary Documentation, dated 7/03, "I. Timing and Expiration of the History and Physical Exam, B. ...If the H&P is over 24 hours old, an interval admission note is required and must be completed within 24 hours of admission or before the planned procedure."