HospitalInspections.org

Based on observation, interview and record review the hospital failed to ensure medical records were completed by physician ID# 54 within 30 days according to the hospital Bylaws.

Findings include:

During initial tour 2/4/14 at 10 a.m. of the medical records department revealed a tall bookcase with numerous patient records on all shelves.

The Medical Records Director (ID# 58) acknowledged that all the records in the bookcase belonged to one physician (ID# 54) and needed signatures. The Director further stated that she does not track how many records are outstanding for signatures or the length of time the records have been delinquent.
The Director further stated the hospital began electronic records on 9/11/13.

The Medical Records Director provided the surveyor with a breakdown of delinquent records for physician ID# 54:

-30 days past due 17
-60 days past due 58
-90 days past due 64
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Total number of medical records past due (greater than 30 days) was 139 medical records for physician ID# 54.

The Chief Executive Officer (ID# 50) stated 2/4/14 at 10:25 a.m. that hospital administration has never formally sent physician ID# 54 a letter of warning / suspension as a result of delinquent medical records.

Record review of "Medical Staff Bylaws" (no date) revealed on page 60 "Medical records: Members of the Medical Staff are required to complete medical records within 30 days of a patient's discharge. A temporary suspension in the form of withdrawal of admitting and other related Privileges until medical records are completed..."