Page 42 - Avoiding Surgical Mishaps Part 1

SVMIC Avoiding Surgical Mishaps: Dissecting the Risks

Documentation

The next area of risk identified
within the surgical specialties is in

documentation. Maintaining a well-
documented medical record, from

both a patient care and a risk
management standpoint, is crucial

to both continuity of care and
protection from challenges to the care provided. Documentation

issues were a factor in 42 percent of claims paid among
surgeons. Of those claims with documentation issues, 45

percent were the result of untimely or delayed documentation
while 39 percent were related to inadequate or omitted

documentation. The remaining categories include illegible
documentation, EHR issues, erroneous documentation, and

inappropriate documentation.

Untimely documentation creates problems with defensibility

because the physician’s memory of an event that happened
days, or even weeks, prior to the documentation of it may

interfere with the accuracy of the written words and attempts
to “catch up” often result in brief, incomplete, or “cookie-cutter”

notes. If there was an intervening event prior to the completion
of the notes, all of the documentation completed after the

intervening event is made to look “self-serving” by the plaintiff.

An example can be seen in the next case study, which involved
a surgeon who dictated the operative note one month after the

initial surgery.

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