HospitalInspections.org

Based on record review and interview it is determined that the medical staff failed to enforce their bylaws by ensuring that their physicians had completed the discharge summary in two (2) of three (3) patients (#1 and #2) closed records that were reviewed. This can adversely impact patient care by not ensuring the discharge record is completed.

Findings include:

1. Hospital Medical Staff By-laws under the Medical Records section last approved in 2013, states in part: "The attending practitioner shall complete the medical record at the time of the patient's discharge, to include progress notes, final diagnosis, and discharge summary." Also, "If the medical record is incomplete thirty (30) days after discharge, a written notice shall be sent to the practitioner by the Administrator notifying him that he has seven (7) days to complete the medical records or privileges to admit new patients, perform new consultations or new procedures will be suspended."

2. Review of the medical record for patient # 2 revealed the patient was admitted to the hospital on 5/13/13 and expired on 5/31/13. No discharge summary was found for this record. The Director of Quality Management was interviewed on 5/22/14 at 0930 hours and agreed the record did not have a discharge summary from the physician as directed by hospital policy. The Health Information and Credentialing Manager was interviewed on 5/22/14 at 1012 hours and agreed that she did not "get all elements of it [the chart] signed. She stated she did not know how this record got "missed". Since she did not report it to the Administrator, the Administrator did not issue a written notice to the attending practitioner.

Based on record review and interview it is determined that the hospital failed to ensure that physicians completed the discharge summary in two (2) of three (3) patients (#1 and #2) closed records reviewed. This can negatively impact patients by not providing continuity of care.

Findings include:

1. Hospital Medical Staff By-laws under Medical Records section last approved in 2013, states in part: "The attending practitioner is shall be responsible for the preparation of a complete and legible medical record for each patient." "The Discharge Summary (clinical resume) shall be written or dictated on all medical records of patients hospitalized." and "All summaries shall be authenticated by the responsible practitioner."

2. Review of the medical record for patient #2 revealed the patient was admitted to the hospital on 5/13/13 and expired on 5/31/13. No discharge summary was found for this record. The Director of Quality Management was interviewed on 5/22/14 at 0930 hours and agreed the record did not have a discharge summary from the physician as directed by hospital policy.