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NORTHWESTERN MEMORIAL HOSPITAL
CONTENT OF RECORD: FINAL DIAGNOSIS
Tag No.: A0469
Based on document review and interview, it was determined, for 2,759 of 8,955 average monthly discharged patients, the hospital failed to ensure medical records were completed within 30 days following patient discharge.
Findings include
1. On 8/4/15 at 10:20 AM, hospital policy #: NMHC PC 05.0021, titled "Medical Records", effective 6/11/14, was reviewed. The policy required, "Discharge Summaries requirements... completed and signed within 30 days of discharge."
2. On 8/4/15 at 10:25 AM, a letter of attestation dated 8/3/15, from the Director of Health Information Management (E #1) was provided. The letter included there were 2,750 delinquent medical records on 8/3/15.
3. On 8/4/15 at 10:15 AM, an interview was conducted with the Manager of Health Information Management (E #5). E #5 stated letters are sent to the physicians who have delinquent medical records and if not corrected, suspension notices are sent.