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KINDRED HOSPITAL SAN ANTONIO
MEDICAL RECORD SERVICES
Tag No.: A0450
Based on review of medical records and interview with staff. Medical record entries are not completed, dated, timed in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This requirement is not met as follows:
Findings:
a. During a review of 6 closed inpatient medical records (MR #1,2,3,4,5 and MR#6) it was observed that all 6 closed medical records reviewed (100%) had medical entries including physician orders, regular and verbal/telephone orders and physician progress notes that were not dated and or timed by the person responsible for providing or evaluating service provided.
b. Interviewed facility staff #13, health information manager at 1:30pm on May 19, 2010 in the administration conference room who also observed the discrepancies and could not provide evidence that these medical records reviewed met the requirements of this regulation.
CONTENT OF RECORD: ORDERS DATED & SIGNED
Tag No.: A0454
Based on review of medical records and interview with staff. All orders including verbal orders are not dated, timed in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This requirement is not met as follows:
Findings:
a. During a review of 6 closed inpatient medical records (MR #1,2,3,4,5 and MR#6) it was observed that all 6 closed medical records reviewed (100%) had medical entries including physician orders, regular and verbal/telephone orders and physician progress notes that were not dated and or timed by the person responsible for providing or evaluating service provided.
b. Interviewed facility staff #13, health information manager at 1:30pm on May 19, 2010 in the administration conference room who also observed the discrepancies and could not provide evidence that these medical records reviewed met the requirements of this regulation.
CONTENT OF RECORD: STANDING ORDERS
Tag No.: A0457
Based on review of medical records and interview with staff. Verbal orders were not dated, timed and authenticated within 48 hours by the prescriber or another practitioner who is responsible for the care of the patient and has been credentialed by the medical staff and granted privileges which are consistent with the written orders. This requirement is not met as follows:
Findings:
a. During a review of 6 closed inpatient medical records (MR #1,2,3,4,5 and MR#6) it was observed that all 6 closed medical records reviewed (100%) had verbal orders that were not dated, timed within 48 hours by the prescriber or another practitioner who is responsible for the care of the patient and has been credentialed by the medical staff and granted privileges which are consistent with the written orders.
b. Interviewed facility staff #13, health information manager at 1:30pm on May 19, 2010 in the administration conference room who also observed the discrepancies and could not provide evidence that these medical records reviewed met the requirements of this regulation.