Missing Admission History and Physical in Resident Medical Record
Summary
A resident was admitted with a left hip replacement and required supplemental oxygen. Upon review of the resident's electronic medical record, the admission History and Physical (H&P) was not present. The Director of Nursing (DON) indicated that the H&P should be in the paper medical record, but it was not found during an initial review of the paper chart. The Medical Records (MR) staff also confirmed the absence of the H&P in the paper chart. Later, the DON located the H&P in the Admissions office and explained that the physician sometimes took H&Ps home and returned them later. The absence of the required admission H&P in the resident's medical record at the time of review constituted the deficiency.
Penalty
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