Failure to Maintain Accurate and Complete Medical Record
Penalty
Summary
The facility failed to ensure the accuracy and completeness of a resident's medical record by not maintaining a signed copy of the admission physician's orders in the electronic health record (EHR). Upon review, it was found that after the resident was readmitted and subsequently discharged to an acute care hospital, the signed Order Summary Report was missing from the EHR. The Health Information Manager (HIM) confirmed that paper records are shredded after scanning, and the signed order should have been present in the EHR but was not. Later, a signed Order Summary Report was produced by the Medical Records Clerk, but the physician confirmed he had signed it only that morning, despite the document being pre-dated. This sequence of events resulted in the resident's medical record containing inaccurate and incomplete information at the time of review.