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ST LUKE'S HOSPITAL BETHLEHEM
EMERGENCY SERVICES POLICIES
Tag No.: A1104
Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to follow its established policy for documentation of medication history for three of 15 Emergency Department (ED) medical records reviewed (MR1, MR2, MR3).
Findings include:
Review on December 13, 2016, of facility policy "Emergency Department General Standards of Care," revised May 2016 revealed " .... E. Documentation ... Certain aspects of patient assessments/screening may be found on the physician documentation and/or nursing documentation. 1. Chief complaint, history of complaint, medical history, medications taken [medication history] ... "
Review on December 15, 2016, of MR1 revealed the patient was admitted to the facility's ED on September 29, 2016. Review of physician documentation for MR1 revealed the "patient takes [pain medications] at home." Further review of physician documentation revealed no documentation of the amount of the pain medication or the time the pain medication was taken prior to the ED visit in MR1. Continued review of MR1 revealed there was no nursing documentation of medication history in MR1.
Review of MR2 on December 15, 2016, revealed the patient was admitted to the facility's ED on September 29, 2016. Further review of MR2 revealed no physician or nursing documentation of medication history in MR2.
Review of MR3 on December 15, 2016, revealed the patient was admitted to the facility's ED on September 29, 2016. Further review of MR3 revealed no physician or nursing documentation of medication history in MR3.
Interview on December 15, 2016, with EMP8 confirmed there was no documentation of the amount of pain medication or the time the pain medication was taken by the patient prior to the ED visit in MR1. EMP8 also confirmed there was no nursing documentation of medication history in MR1. Further interview with EMP8 confirmed there was no physician or nursing documentation of medication history in MR2 and MR3.