HospitalInspections.org

Based on document review and interview the hospital failed to complete 244 medical records within 30 days of discharge or outpatient care.

Findings included:

- Staff B on 3/8/10 at 12:50pm reported the hospital currently had 244 delinquent records. The hospital provided a ChartFact Chart Aging Report on 3/10/10 at 10:25am. Review of the report summary detailed the following:

- 68 medical records 31-60 days delinquent
- 44 medical records 61-90 days delinquent
- 25 medical records 91-120 days delinquent
- 8 medical records 120-150 days delinquent
- 11 medical records 151-180 days delinquent
- 88 medical records over 180 days delinquent

Review of hospital policy "Delinquent Medical Records," effective date June 1, 2003 (revised 11/05, 6/08) directed..."Medical records should be completed within thirty (30) days after discharge..."

Staff B on 3/8/10 at 12:50pm confirmed the process they use to track late records. Staff B explained they run reports and looked at where they are at daily, attempts to contact the doctors and verbally notify them of delinquent charts. Staff B explained that if the records remain delinquent, a letter is then sent to the doctor's office notifying them of delinquent charts on their service. If charts remain delinquent, they forward the information administration for further follow-up.

Review of hospital policy "Delinquent Medical Records," effective date June 1, 2003 (revised 11/05, 6/08)directed..."Courtesy reminder letters will be sent to the physician notifying him/her of their incomplete records...If the records are still delinquent at fifteen (15) days, a letter will be sent to the physician notifying him/her of the patient's records to be completed...In the event that the charts have not been completed within the time frame set forth by the medical executive committee, a list of delinquent physicians or staff personnel will be forwarded to the committee for consideration..."

Staff A on 3/10/10 at 2:30pm confirmed they were recently made aware there was a breakdown in the process for ensuring timely completion of medical records.