Physician Failed to Timely Sign and Date Progress Note
Penalty
Summary
A deficiency was identified when a physician failed to sign and date a resident's progress note at the time of the visit. The resident, who had multiple diagnoses including depression, anxiety disorder, sepsis, hyperlipidemia, and intrahepatic bile duct carcinoma, was admitted to the facility and underwent an initial psychiatric consultation. The consultation note included clinical observations and recommendations, such as continuing and potentially adjusting antidepressant medication. However, the physician did not sign and date the progress note until 52 days after the visit. This lapse was discovered through a review of the resident's medical record and confirmed during a staff interview. The nurse's note documented that the resident was seen by the behavioral MD and that a new medication order was entered, but the corresponding physician's note was not signed and dated contemporaneously. The physician acknowledged the delay, attributing it to a habit of reviewing notes later and sometimes forgetting to sign them.