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Based on record reviews, and staff interviews the hospital failed to ensure that a medical history and physical examination was dated and time prior to surgery or a procedure requiring anesthesia services for 4 (#5, #7, #11, #12) of 4 focused sample medical records reviewed for surgical services completed by S9 Surgeon, out of a total of 8 sample records reviewed (#6, #8, #9, 10). Findings:

Patient #5
Review of patient #5's medical record revealed she is a 64 year old female who was admitted/discharge on 2/19/13 for outpatient surgical services for EGD (Esophagogastroduodenoscopy), and Colonoscopy. when the examination was performed. Further review revealed a medical history and physical (H&P) report signed by S9 Surgeon with no date documented revealing when the examination was performed.

Face to face interview on 2/20/13 at 2:00 p.m. with S7 RN, (Registered Nurse) OR, (Operating Room) Manager, revealed H&Ps were to be dated and timed prior to any surgical procedure. S7 RN confirmed there was no documented date nor time on the H&P that was completed by S9 Surgeon.

Face to face interview on 2/ 20/13 at 2:30 p.m. with S8 HIM (Health Information Manager) when asked identified the form in patient #5's record as being the H&P form used by S9 Surgeon. S8 HIM confirmed there were no areas on the form which indicated the date or time of the H&P.

Face to face interview on 2/21/13 at 10:00 a.m. with S1 DON ( Director of Nursing) and S2 RN (Registered Nurse) confirmed that all surgery and or procedure history & physical should be dated and timed.

Patient #7
Review of patient #7's medical record revealed that she is a 56 year old female who was admitted on 2/19/3 for outpatient procedure (Colonoscopy) and was discharge on that same day. Further review revealed a H&P report signed by S9 Surgeon with no date documented revealing when the examination was performed.

Face to face interview on 2/20/13 at 2:00 p.m. with S7 RN, OR Manager, revealed H&Ps are to be dated and time prior to procedure. S7 confirmed there was no documented date nor time on the H&P that was completed by S9 Surgeon.

Face to face interview on 2/ 20/13 at 2:30 p.m. with S8 HIM Manager when asked identified the form in patient #7's record as being the History & Physical form used by S9 Surgeon. S8 HIM confirmed there were no areas on the form which indicated the date or time of the H&P.

Face to face interview on 2/21/13 at 10:00 a.m. with S1 DON and S2 RN confirmed that all surgery and or procedure H&P should be dated and timed.

Patient#11
Review of patient #11's medical record revealed that she is a 53 year old female who was admitted on 1/15/13 for outpatient procedure (Colonoscopy with HOT Polypectomy, COLD biopsy, & submucosal injection of tattoo) and discharged on the same day. Further review revealed a H&P report signed by S9 Surgeon with no date documented revealing when the examination was performed.

Face to face interview on 2/20/13 at 2:00 p.m. with S7 RN, OR Manager, revealed H&Ps are to be dated and time prior to procedure. S7 confirmed there was no documented date nor time on the H&P that was completed by S9 Surgeon

Face to face interview on 2/ 20/13 at 2:30 p.m. with S8 HIM Manager when asked identified the form in patient #11's record as being the H&Pl form used by S9 Surgeon. S8 HIM confirmed there were no areas on the form which indicated the date or time.

Face to face interview on 2/21/13 at 10:00 a.m. with S1 DON and S2 RN confirmed that all surgery and procedure, H&P should be dated and timed.

Patient #12
Review of patient #12's medical record revealed that he is an 84 year male who was admitted on 2/12/13 for Colonoscopy and was discharged on that same day. Further review revealed a H&P report signed by S9 Surgeon with no date documented revealing when the examination was performed

Face to face interview on 2/20/13 at 2:00 p.m. with S7 RN, OR Manager, revealed H&Ps are to be dated and time prior to any surgical procedure. S7 confirmed there was no documented date nor time on the H&P that was completed by S9 Surgeon.

Face to face interview on 2/ 20/13 at 2:30 p.m. with S8 HIM Manager when asked identified the form in patient #12's record as being the H& P form used by S9 Surgeon. S8 HIM confirmed there were no areas on the form which indicated the date or time.

Face to face interview on 2/21/13 at 10:00 a.m. with S1 DON and S2 RN confirmed that all surgery and procedure H&P should be dated and timed.