Question

As an HIM chart analyst, you are reviewing the chart of a patient who was admitted on 2/17 with gallstone pancreatitis. She arrived through the emergency roont on Wednesday afternoon in severe abdominal pain. After lab work was performed showing an increased lipase level, she was admitted. Her family physician evaluated her the next morning and ordered an ultrasound, and repeat lab work. The ultrasound showed gallstones and the lab work indicated the lipase was coming down. He consulted a general surgeon who evaluated the patient and agreed to perform a cholecystectomy on Friday if the lipase level returned to near normal levels. Surgery was then performed on Friday morning, and after an uneventful night, the patient was discharged home on Saturday morning. On 2/25, you have the following documentation available in the EHR: H&P dictated 2/18 authenticated 2/18 Consultation report dictated 2/18 authenticated 2/23 Immediate post-op note written 2/19 authenticated 2/19 Operative report dictated 2/20 authenticated 2/21 Discharge summary dictated 2/22 authenticated Lab work from all dates of stay Nursing notes from all dates of stay Anesthesia documentation from surgery Physician orders from all dates of stay -all signed Progress notes-all signed Medication list-signed You analyze the above information and identify that the record is not complete. 1. List the reason(s) for your determination of an incomplete record. 2. List the steps that must be taken to get the record complete in the required time frame.

Answer 1

1. The patient was admitted on 2/17. it was a wednesday. on Friday  the patient got operated for cholecystectomy, that is on 4 /17. But in the reports the dates are given wrong. Consultation report and H/P is on 2/18 which is wrong entry. The operative report is written on 2/20 which was actually on 4/17. the patient got discharged on 5/17. but the discharge summary is dictated on the date 2/22 which is wrong. the authentication date is not given for discharge summary.

2. To get the complete record, the staff must be up to date in documentation. all the necessary steps for documentation has to be given importance. All the dates must be proper.

Answer 2

I would like to know how you come up with your answer. It clearly states that on 2/17 the patient was admitted. This was a wed. So thursday the 18th her PCP examed her and the specialist agreed to do the surgery on friday 2/19 as long as the levels remained down which they did so on 2/19 the surgery occured. she was then discharged by 2/20.