Submitted by Robert L. Benz, MD, LMC Vice President, Medical Affairs, and Margie Iacobacci, RN, MSN, CNOR, LMC Vice President, Patient Services
During a recent Department of Health (DOH) visit, it was noted that we were not fully compliant with signing, dating, and timing H&Ps and H&P Update stickers for patients undergoing surgery and procedures.
We were asked by DOH to perform internal audits in order to undue our citation on this matter. Unfortunately, the audits confirmed a poor compliance rate. And, DOH intends to cite us a 2nd time.
Thus, to bring us into 100% compliance, nurses in the OR and procedural areas have been instructed not to proceed with any procedure if the H&P, updated pre-procedure H&P and anesthesia note are not fully completed and signed.
The best way to avoid any inconvenience to ourselves, our staff and most importantly our patients is to date, time and sign and fill-out the appropriate paperwork each and every time. This is what the DOH expects of us.
Please note that the above documents must be signed by a member of the Medical Staff. Thus, residents, fellows and mid-level provider signatures are not adequate to fulfill this requirement.
As always, feel free to call Margie or me with any questions or concerns. However, this is a state regulatory requirement.