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HIGHCREST HOSPITAL OF WICHITA FALLS
MEDICAL RECORD SERVICES
Tag No.: A0450
Based on interview and record review, the nurses' notes documented on Patient #1's medical record was not legible that one could not comprehend what the nurses were trying to convey, citing 2 of 8 nurses (Personnel #7 and #8) who were the primary care nurses of Patient #1 from 09/18/2020 to 09/23/2020.
Findings:
The hospital did not have electronic medical record capability. The Nurses' Notes were documented on paper. The Nurses' Notes dated 09/20/2020 and 09/21/2020 (7:00 PM to 7:00 AM) by the night shift nurse (Personnel #8) were not legible. The Nurses' Notes dated 09/21/2020 (7:00 AM to 7:00 PM) by the morning shift nurse (Personnel #7) was not legible.
In an interview on 10/06/2020 at 11:06 AM over the telephone, Personnel #1 confirmed that the Nurses' Notes were not legible.
Policy # HIM.I.13 "Hospital Chart Completion" revised 12/28/2018 page 5 required "The legibility of all chart entries is as critical to patient care as the timeliness. Therefore, all entries in the medical record must be legible..."