HospitalInspections.org

Medical record review conducted on 06/21/19 indicated that, for Patient #2, there was no order to discontinue Ativan (an axiolytic) yet the medication was discontinued by the nurse (without physician order documentation). Record review also did not identify any nursing documentation to indicate that the Ativan order was discontinued.

The Surveyor interviewed Nurse #2 on 06/24/19 at 9:30 A.M. Nurse #2 said that the expectation is that the nurse must contact the physician to clarify any order changes and subsequently document those changes in the patient chart.

The policy titled Electronic Health Record Documentation, last revised 02/06/2018, indicates that all documentation should be completed within 24 hours of the patient encounter; that is, the document has been created, the clinical content entered and electronically signed by the LIP (Licensed Independent Practitioner).

Medical record review conducted on 06/21/19 indicated that, for Patient #5, the history and physical examination that was initiated by a physician assistant on 06/19/19 was missing the required signature/co-signature, signifying an incomplete record.