HospitalInspections.org

Based on review of Medical Staff Rules and Regulations and review of medical records, the hospital failed to ensure that all entries are timed when entered into the medical record, and that all verbal and/or telephone orders are signed by the physician within 48 hours.

Findings include:

1. On six (6) of 10 inpatient medical records reviewed, all progress notes had not been timed when entered into the medical record.

2. On nine (9) of 10 inpatient medical records reviewed, all physician orders had not been timed when entered into the medical record. This included those orders written by the physician, verbal orders taken by a nurse, and routine order sheets.

3. All verbal orders had not been authenticated by the physician within 48 hours on nine (9) of 10 inpatient medical records reviewed.

Based on review of Medical Staff Rules and Regulations and review of medical records, the hospital failed to ensure that informed consents are properly executed.

Findings include:

The Consent for Operative and Invasive Procedures has a section for the physician to sign stating that he has reviewed the risks, benefits, and alternatives with the patient and/or legally responsible person. The 10 inpatient medical records reviewed contained a total of 11 operative consents. The physician had not signed the consent on nine (9) of the 11 consent forms.