HospitalInspections.org

Based on staff interview and review of medical records, the hospital failed to ensure that records of discharged patients were completed within 30 days of discharge.

Findings include:

A count of incomplete medical records revealed a total of 276 discharged medical records that were delinquent over 30 days. Of this number, 107 of the medical records dating back to November, 2010 belonged to one (1) physician.

Further review revealed that another physician had 13 delinquent records that dated back to May, 2009, along with 71 delinquent Emergency Room records that dated back to July, 2011. The delinquent records lacked dictation and/or signatures.

Interview with the Director of the Medical Record Department on 01/11/2012, revealed that delinquent medical records from October, November and December, 2011 related back to the fact that in October 2011, two (2) coders left. Discharged medical records are checked for deficiencies when they are coded, and then placed in the physician's incomplete files for completion. The Director stated that since the coders were behind and were just now coding discharges from the last week of November, 2011, discharged medical records were delinquent before they are given to the physicians to complete. The Director also stated that the Medical Record Department was not counting the number of delinquent medical records and reporting the numbers to the Administration each month.