HospitalInspections.org

Based on record review and staff interview it was determined the facility failed to ensure dictated documentation in the medical record was authenticated by the person responsible for providing the service for 1 of 11 patients (#3) whose record was reviewed. This failure in the dictation/transcription system had the potential to impact the medical records of all patients cared for at the facility. Lack of an appropriately authenticated document led to an inaccurate medical record. Findings include:

Patient #3 was a 60 year old female admitted to the hospital on 3/25/11 for care related to a wound on her heel, congestive heart failure, and chronic obstructive pulmonary disease. She was discharged from the hospital on 5/05/11.

Her medical record contained several dictated and transcribed documents including the following:

- A "HISTORY & PHYSICAL" dictated on 3/25/11. A line at the end of the dictation indicated, "Electronically viewed and signed on 03/26/2011 11:18:08 by [physician name]."
- A "DISCHARGE SUMMARY" dictated on 5/26/11. A line at the end of the dictation indicated, "Electronically viewed and signed on 05/27/2011 10:17:55 by [physician name]."

It was not clear who dictated these documents.

The PA who cared for Patient #3 was interviewed on 2/23/12 at 10:45 AM. She reviewed the medical record and explained that she was the provider who completed and dictated the "HISTORY & PHYSICAL" on 3/25/11, not the physician. She stated the physician had dictated the "DISCHARGE SUMMARY." She confirmed that based on the report in the medical record the author of either report could not be determined. She explained the physician must have viewed and electronically co-signed the report before she did. She stated when the physician electronically signed a document before a PA was able to, only one signature, that of the physician, made it to the printed copy of the report. She stated if she would have electronically signed the report first, and the physician signed after her, then both signatures would have been on the report. She confirmed that it would be difficult to determine which scenario had occurred and therefore who was the true person responsible for providing and dictating the service.

The Health Information Management Director was interviewed on 2/24/12 at 11:50 AM. She confirmed that a dictated report would not indicate who dictated the note unless the dictator specifically said so and it was subsequently transcribed into the report. She explained that once a PA completed dictating a note, the dictation was sent to an electronic "box" for review by both the PA and the physician. She confirmed that if the physician viewed and signed the dictation first and the PA signed second, then the PA's name would not show up in the printed report, even if the PA dictated the report. She stated if the PA viewed and signed the report first, and then the physician viewed and signed it, both names would be clearly indicated on the report. However, the Director confirmed that even if the PA's and the physician's names appeared on the report, it would still not show who actually dictated the report. She explained the hospital's dictation system generated a log that listed the name of the individual and the date and time of a dictation. She stated the log did not correlate which document was dictated by who and when it was dictated. She explained that to determine who dictated what, the date and time of the printed document was compared to the log, which listed the date and time of the document in conjunction with the individual who dictated the report.

The facility failed to ensure documentation in the medical record was authenticated by the person responsible for providing the service.