Page 47 - Avoiding Surgical Mishaps Part 1

SVMIC Avoiding Surgical Mishaps: Dissecting the Risks

you.

A similar caution applies to outside consultations and surgical

clearances. The surgeon should either review a copy of the
dictated consult or speak to the physician involved. There

may be medical information in the consult that is not available
elsewhere in the chart. The consultant may have had access to

old records or to history from the patient’s relatives that is not
available to you. These efforts need to be documented.

Document timely and completely - including history, pre-op
workup, instructions, telephone calls, the rationale for actions

that may not be self-evident, and post-op instructions and
warnings.

Electronic Health Records

Although the use of an electronic health record can offer many

benefits such as clinical decision support tools, improved
legibility, and interoperability, there continue to be risk issues.

The most significant risk issue is with copy and paste. If using an
EHR, review and correct all documentation that may have auto-

populated or been carried over from a previous visit to ensure it
is an accurate reflection of the current office visit assessment.

The use of a copy and paste capability to create the new

note from the old one is fraught with potential risk. Copying
information from a prior note and pasting it into a new note

may result in notes which are identical, perpetuate outdated
or incorrect information, and produce voluminous progress

notes that obscure important new information. In litigation,
repetition of identical notes, including errors in those notes, will

raise questions about whether or not the physician reviewed

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