Delayed Upload of Psychiatric NP Notes to Medical Record
Penalty
Summary
Surveyors identified a deficiency related to the timeliness of physician and NP documentation being available in the medical record following resident visits. For one resident reviewed during a complaint survey, the medical record showed multiple psychiatric evaluations and consultations by a psychiatric NP, but the completion dates of these assessments did not match the dates they were uploaded into the resident’s electronic record. In some instances, there was up to a month delay between the date the NP completed the evaluation and the date the note was uploaded into the miscellaneous section of the record. During review on one survey date, several psychiatric visit notes following an incident were not yet present in the resident’s record, despite the visits having already occurred. Further review and interviews with the NHA and DON confirmed that the process for handling the psychiatric NP’s documentation involved a delay between completion of the notes and their receipt and upload by facility staff. The DON reported that the staff member responsible for medical records uploads the NP’s documents as soon as they are received, indicating that the lag occurs before the notes reach the facility. Surveyors noted that this delay affected not only general progress notes but also notes containing medication changes, including an example where a note documenting an increase in Trazodone was completed on one date and not uploaded until several days later. The deficiency centered on the lack of timely availability of physician/NP notes in the resident’s medical record after visits and assessments had been completed.
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