Every finding on record at Valley Creek Hospice Care

Upon patient record review, 1 of 14 (Patient #7) 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. #7-SN documented no pain in the pain section of the SN note dated 03/09/25, but pain was documented as 2/10 in the narrative. SN selected None for edema in the cardiovascular section of the 03/23/25 nursing note. In the SN Narrative, there was documentation of +2 pitting edema in both lower extremities.