HospitalInspections.org

Based on record review and interview the facility failed to ensure that all medical record evaluations and care provided were completely documented for one patient in a survey sample of twenty two patients. (Patient identifier is #22)

Findings include:

During survey conducted on 6/9/17 a review of patient #22 medical record was completed. The review identified that this patient arrived at the hospital via ambulance, received a medical screening and received treatment. Hospital to hospital and physician to physician communication took place and the patient was transferred. The complete record of this patients time in the Emergency Department had to be constructed from several sources in addition to the actual medical record. The patient transfer sheet was not in the medical record. Interview with ambulance supervisor and emergency room manager identified that the form had been filled out and was sent with transfer team. The portion of form that should have been left with the referring facility had been sent with transfer.