HospitalInspections.org

Based on document review and interview, it was determined that the hospital failed to ensure the completion of medical records within 30 days of patient discharge.

Findings include:

1. On 07/02/2025, the hospital's policy titled, "Medical Staff Suspensions, HIM (Health Information Management)" (revised 04/28/23) was reviewed and included, "Medical Staff Bylaws states a Physician who fails to complete available medical records within fourteen (14) days of a patient's discharge shall be subject to suspension... C. 1. Physicians are expected to complete all incomplete records and may be subject to suspension if he/she does not complete all delinquent records which include: History and Physical ... ED provider notes ... Consult notes ... verbal orders not signed within 48 hours ..."

2. On 07/02/2025, the hospital's Supervisor of Health Information Management (E #7) provided a Delinquent Record log dated June 2025 to current and indicated that there were a total of six (6) delinquent records for (the hospital).

3. On 07/02/2025 at approximately 9:40 AM, an interview was conducted with the Supervisor of HIM (E #7). E #7 stated, "Records are considered delinquent if not completed within 30 days, including history & physical and discharge summary. Currently there are six delinquent records or incomplete history and physical and the discharge summary. I reach out the providers to remind them of the requirements."