HospitalInspections.org

Based on record review and interview, the facility failed to ensure the medical staff followed and were held accountable to the approved medical staff bylaws in the documentation of a patient's history and physical in 1 of 10 records reviewed (Patient ID #1).

Findings include:

Record review of patient's (ID#1) medical record for outpatient procedure performed by physician (ID#57), date of service 4/24/2017 contained a history and physical dated 2/17/2017 with a cover page dated 12/6/2017 stating the following: Please see the attached History & Physical that has been requested from your facility.

Interview with physician (ID# 57) on 12/6/2017 revealed that he makes sure there is a history and physical in each patient record before any procedure. If there is one in the chart that is within a certain time frame, I think ninety days or something, I will hand write whether or not there are any changes in the patient's condition.

Interview with Chief Nursing Officer (ID# 54) on 12/6/2017 at 12:49 PM revealed that the history and physical was not in the medical record. The copy provided was faxed over today from the referring physician.

Record review of facility Medical Staff Bylaws dated March 2016, revealed the following information:
Article 13: History and Physical
13.1 Timing of the History and Physical Examination

13.1.1 A complete medical history and physical examination must be performed and documented in the patient's medical record within 24 hours after admission or registration (but in cases prior to surgery or an invasive procedure requiring anesthesia services). The history and physical examination must be performed by a Practitioner who has been granted clinical privileges by the hospital to perform history and physicals.

13.1.2 If a medical history and physical examination has been completed within the thirty-day period prior to admission or registration, a durable, legible copy of this report may be used in the patient's medical record, if the history and physical examination was performed by a physician, oral maxillofacial surgeon, physician assistant, or advanced practice registered nurse. In such cases, within 24 hours after admission/ registration or prior to surgery or invasive procedure, whichever comes first, the patient must be reassessed by a Practitioner that has been granted clinical privileges by the hospital to perform history and physicals. The purpose of this assessment is to identify any changes subsequent to the original examination. The practitioner must update the history and physical examination to reflect any changes in the patient's condition since the date of the original history and physical or state that there have been no changes in the patient's condition.