HospitalInspections.org

Based upon review of 1 of 6 medical records (#6) and staff interview, the hospital failed to ensure patient #6's medical record was completed within 30 days following discharge on 1/24/14. This was evidenced by Physician S12's failure to complete a Discharge Summary on patient #6. Findings:

Review of patient #6's medical record revealed on 1/24/14, the patient required transfer to an acute care hospital and was therefore discharged from the hospital. Further review of the medical record on 3/25/14 revealed there failed to be evidence Physician S12 completed a Discharge Summary on patient #6 even though 60 days had passed since the patient was discharged.

Interview with S5 Health Information Director on 3/25/14 at 10:30 a.m. confirmed Physician S12 had not dictated or completed a hand written Discharge Summary for patient #6.