Every finding on record at Sk Hospice Care, Inc

Upon patient client record review, 2 of 5 records (Patient #2,#3) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #2: The narrative of the social work assessment dated 7/8/23 indicated a 68 year old Caucasian female who is diagnosed with Chronic Obstructive Pulmonary Disease. The record did not contain evidence that the patient had COPD. The primary diagnosis was Hypertensive Heart Disease with Failure. Patient #3: The narrative of the social work assessment dated 7/8/23 indicated a 67 year old male admitted to hospice for the diagnosis of terminal illness. The record indicated that the diagnosis was Hypertensive Heart Disease with Failure.