HospitalInspections.org

Based on record review and interview, the facility failed to ensure medical record entries had appropriate signatures: history and physical, code sheet, and health care plans on 1of 3 closed records and 7 in patient records, patient #.2.

Findings include:

Review of patient #2's medical record on 3/12/13 revealed the following:
1. History and physical dated 11/30/12 was not signed by the physician.
2. Code sheet dated 12/1/12 was not signed by the physician
3. Health care plan dated 12/1/12 was not signed by the physician.

Patient # 2 was admitted at the facility on 11/30/12 to 12/9/12. Review of facility medical record policy on 3/12/13 revealed the following:

"Medical records that are imcomplete thirty (30) days after patient discharge are considered delinquent". "When a physician has medical record thirty (30) days or greater from the date of discharge, the physician will be notified of delinquent medical records". The physician will be sent a letter requiring completion of the delinquent charts before sixty (60) days delinquent". "If the physician has any medical records in a delinquent status at sixty (60) days post discharge then the physician's privileges will be automatically suspended".

Patient #2's medical record had been delinquent more than 60 days.

There was no documentation indicating that the facility took any of the actions as stated in their medical record policy.

Interview with facility staff # 3 (QA) on 3/12/13 at 12:30pm in the conference room revealed the documents above should have been signed by the physician and that a letter should have been sent out after sixty (60) days.

Interview with facility staff # 5, medical record staff on 3/12/13 at 12:40pm in the conference room revealed she had not sent any letter to the physician regarding the above delinquent medical record.