HospitalInspections.org

Based on document review, medical record review and staff interview, the facility failed to ensure a discharge summary was written and/or dictated by the physician and in the medical record for 2 of 5 (N1 and N2) closed patient medical records reviewed.

Findings:

1. Policy titled, "Completion Requirements for the Medical Record", reviewed on 2/7/11 at 1:10 PM indicated:
A. on pg. 2, under section I. General Requirements, "The information contained in the medical record shall serve to identify the patient, support the diagnoses, document treatment rendered, justify treatment rendered and accurately document the patient results of this treatment. Generally, the medical record will contain the following informational items...J. Clinical Resume (Discharge Summary)."
B. on pg. 3, under section III. Applicable Medical Record Forms and Documentation Requirements, point B., "Discharge Summary (Clinical Resume), 1. The Clinical Resume should be dictated by the attending physician upon discharge of the patient from the Hospital..."

2. Review of closed patient medical records on 2/7/11 at 12:45 PM, indicated patient:
A. N1 was admitted on 10/29/10 and expired on 12/14/10 and lacked a Discharge Summary.
B. N2 was admitted on 10/28/10 and discharged on 11/10/10 and lacked a Discharge Summary.

3. Personnel P1 was interviewed on 2/7/11 at 12:01 PM and indicated the above mentioned patient medical records were lacking documentation of a written and/or dictated Discharge Summary as required per facility policy and procedure.