HospitalInspections.org

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Based on record review and interview, the hospital failed to ensure patient medical records had a current detailed History and Physical prior to surgery or a procedure requiring anesthesia services for 3 (#7, #12, #15) of 30 patients reviewed who had surgical procedures.

Findings:

Review of hospital policy titled "Content of the Medical Record", updated 2022, revealed in part: The physician must document any additions to the history or changes in the patient's current physical findings that might be significant for the planned course of treatment and must be signed, dated, and timed. Admitting diagnosis will be documented on all admissions. History and physical exams must include chief complaint, history of present illness, past medical history, family history, social history, review of systems, medications, and allergies, physical examinations, provisional diagnosis or clinical impression and treatment plan.

Patient #7
Review of the medical record revealed patient #7 was admitted to the hospital on 11/02/2021with a diagnosis of bilateral knee pain. The History & Physical dated 10/14/2021 revealed no detailed documentation for past medical history, past surgical history, current medications, allergies, family medical history, social history, review of systems. S5Surgeon documented Reviewed per patient questionnaire, discussed with patient and incorporated in the patient's permanent chart.

Patient #12
Review of the medical record revealed patient #12 was admitted to the hospital on 12/14/2021with a diagnosis of left arm pain. The History & Physical dated 12/14/2021 revealed no detailed documentation for past medical history, past surgical history, current medications, allergies, family medical history, social history, review of systems. S5Surgeon documented Reviewed per patient questionnaire, discussed with patient and incorporated in the patient's permanent chart.

Patient #15
Review of the medical record revealed patient #15 was admitted to the hospital on 01/11/2022 for a surgical procedure. The chart contained a History & Physical form dated 01/11/2022, but revealed no detailed documentation for past medical history, past surgical history, current medications, allergies, family medical history, social history, and review of systems. The physician documented there were no changes since the last History & Physical obtained at an office visit on 12/28/21. The 12/28/21 History and Physical was not contained in the medical record. S5Surgeon documented Reviewed per patient questionnaire, discussed with patient and incorporated in the patient's permanent chart.

Interview on 01/11/2022 at 12:30 p.m. with S4HIM confirmed patient #7 and #12 History & Physical had no documentation of detailed systems, and that the completed History and Physical should be available on the current medical record prior to surgery.