Medical staff members are reminded again
that:
- All medical record entries (including progress
notes) must be signed, dated and timed
- Verbal orders and telephone orders must be
signed, dated and timed within 48 hours. On-call
colleagues may and should sign each other's
orders.
- Restraint orders must be signed, dated and timed
within 24 hours. On-call colleagues may and should
sign each other's orders.
- Informed consents must be provided to patients or
family members. The attestation must be
documented in the medical record either in the
operative note or the procedure note. The
documentation must indicate that the procedure's
risks, benefits and options have been discussed.
Charts are being flagged and reminder calls are
being
made, but it remains the medical staff member's
responsibility to assure his/her documentation is
appropriately authenticated.
