HospitalInspections.org

1. Based on review of medical record #1, 80 year old male and interview with staff it was observed that the physician progress notes were not timed and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedure.

Findings:

a. Reviewed medical record #1, 80 year old male it was observed that out of 22 physician progress notes 21 out of the 22 physician progress notes (95%) were not timed and authenticated by the physician progress notes.

b. Interviewed staff #1 , Rehabilitation Nurse Manager and Staff # 3, Vice President of Nix Specialty Health Center and showed and explained the physician progress notes. The staff interviewed agreed that physicians should be dating, timing and authenticating all medical entries and could not show that this requirement was met with the physician progress notes.