Page 45 - Avoiding Surgical Mishaps Part 1

SVMIC Avoiding Surgical Mishaps: Dissecting the Risks

In addition to untimely documentation, inadequate or omitted

documentation was seen in 39 percent of the claims reviewed.
Examples of inadequate documentation include:

• Incomplete preoperative patient histories

• Insufficient information to outline the rationale behind
treatment or surgical decisions

• Sparse/lacking documentation of information given during
informed consent process

Most often, there was a failure to completely document the

extent and details of a physical examination or history, discharge
instructions, and telephone calls. The note should describe

what took place, what you were thinking, and what you told
the patient. Document your phone conversations with other

physicians to include name, date, and time of call as well as the
essence of the exchange.

When documenting the physical exam, it is important to
document, in detail, the extent of your physical exam and avoid

ambiguous documentation such as “GI normal” as this may be
difficult to defend.

Your medical history and exam should pay special attention to

pre-op tests ordered and the results. There should be a tracking
system to ensure pre-op tests ordered are recognized and

reviewed as they may have implications on whether a medical
clearance consult is needed. Look for and document any

significant comorbidities or history that can increase the risks of
surgery or expected healing such as:

• Obstructive sleep apnea

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