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UNIVERSITY OF VERMONT MEDICAL CENTER 111 COLCHESTER AVE BURLINGTON, VT 05401 July 15, 2014
VIOLATION: MEDICAL ORDERS FOR RADIOLOGY SERVICES Tag No: A0539
Based on staff interview and record review, the hospital failed to assure that radiology services were provided only on order of a complete and properly documented provider order for 1 of 10 patients in the targeted sample. (Patient # 3). Findings include:

Per review on 7/14/14, Patient #3's provider order for a radiology test, written by a referring provider from another health care entity on 11/25/13 and faxed to FAHC on 11/26/13, was improperly documented to reflect a clarification of provider orders by hospital staff. During interview on 7/15/14 at 10:30 AM, the scheduling specialist stated that she received a telephone call from the other clinic's scheduler, in response to an emailed request by FAHC Radiology to add another ultrasound view to the ordered tests (due to the patient's stated symptoms). The caller from the other clinic informed the FAHC radiology staff that it was OK to add the additional test to the patient's 12/10/13 scheduled test. In completing the documentation on the faxed provider order, the FAHC staff failed to sign, date and time the entries made on the provider order. When the Director of Radiology Services was asked (7/15/14 at 11 AM) for a copy of the hospital's procedure for order clarification in this case, she confirmed that there was no written procedure. During interview on 7/15/14 at 9:30 AM, the physician Section Head for Radiology Ultrasound and Chair for Quality Assurance confirmed that the clarification to provider orders was not documented properly in this case.