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FRIO REGIONAL HOSPITAL
CONTENT OF RECORD: ORDERS DATED & SIGNED
Tag No.: A0454
1. Based upon review of inpatient medical records and interview with hospital staff verbal orders regular orders are not being dated and timed within hospital policy guidelines and federal and state law within 48 hours by practitioner. This requirement is not met as follows:
Findings:
a. In review of 6 inpatient medical records (MR#) (MR# 1,2,3,4,5,and MR#6) 3 out of the 6 inpatient medical records (MR) (50%) (MR# 3,4, and MR# 5) reviewed had verbal orders or telephone orders that were not timed or dated by physician and or practitioner within 48 hours.
b. Interviewed staff #3, Director of Health Information Management at 2:30pm on Feb 4, 2010 in the facility's conference room who also reviewed and observed the same discrepancies in section (a) and could not provide evidence that the records reviewed met the requirements of this regulation.
CONTENT OF RECORD: STANDING ORDERS
Tag No.: A0457
1. Based upon review of inpatient medical records and interview with hospital staff verbal orders are not being dated and timed within hospital policy guidelines and federal and state law within 48 hours by practitioner. This requirement is not met as follows:
Findings:
a. In review of 6 inpatient medical records (MR#) (MR# 1,2,3,4,5,and MR#6) 3 out of the 6 inpatient medical records (MR) (50%) (MR# 3,4, and MR# 5) reviewed had verbal orders or telephone orders that were not timed or dated by physician and or practitioner within 48 hours.
b. Interviewed staff #3, Director of Health Information Management at 2:30pm on Feb 4, 2010 in the facility's conference room who also reviewed and observed the same discrepancies in section (a) and could not provide evidence that the records reviewed met the requirements of this regulation.
CONTENT OF RECORD: UPDATED HISTORY & PHYSICAL
Tag No.: A0461
Based upon review of medical records and interview with staff. Documentation of the updated medical History and examination are not completed and placed in the patient's medical record within 24 hours after admission or registration. This requirement is not met as follows:
Findings:
a. In review of 6 inpatient medical records (MR#) (MR# 1,2,3,4,5,and MR#6) 6 out of the 6 inpatient medical records (MR) (100%) (MR# 1,2,3,4,5 and MR# 6) reviewed had history and physicals examinations (H&P) documentation that were not dictated and transcribed and placed in the medical record within 24 hours.
- MR #1 the patient was admitted on 12/09/09. H&P was dictated on 12/13/09 and transcribed/placed in record 12/16/09
- MR #2 the patient was admitted on 12/17/09. H&P was dictated on 12/18/09 and transcribed/placed in record 01/06/10
- MR #3 the patient was admitted on 12/22/09. H&P was dictated on 01/24/10 and transcribed/placed in record 01/24/09
- MR#4 the patient was admitted on 12/25/09. H&P was dictated on 12/29/09 and transcribed/placed in record 12/29/09
- MR#5 the patient was admitted on 12/26/09. H&P was dictated on 12/30/09 and transcribed/placed in record 12/31/09
-MR#6 the patient was admitted on 01/02/10. H&P was dictated on 01/05/10 and transcribed/placed in record 01/05/10.
b. Interviewed staff #3, Director of Health Information Management at 2:30pm on Feb 4, 2010 in the facility's conference room who also reviewed and observed the same discrepancies in section (a) and could not provide evidence that the records reviewed met the requirements of this regulation.