Page 48 - Avoiding Surgical Mishaps Part 1

SVMIC Avoiding Surgical Mishaps: Dissecting the Risks

the note for accuracy when the accuracy of a medical record is

questioned the trustworthiness of any portion of that record is
then also questioned. An example of a copy and paste error is

seen in the following case.

CASE STUDY

A 60-year-old nurse practitioner with a history of a prior
hysterectomy underwent laparoscopic sigmoid colectomy

by a general surgeon due to recurrent diverticulitis. The
preoperative report, which was carried forward and

documented in the EHR, included a rectovaginal exam
revealing an anteverted uterus that was billed to the patient’s

insurance, although the exam never took place.

Following the colectomy, at her first post-op visit, she
complained of drainage from her incision, flank pain, fever,

and frequency and urgency with urination. The EHR also
carried forward documentation of an examination of the skin,

head, ears, eyes, nose, and throat which would not ordinarily
be performed in an abdominal post-op exam. She was

prescribed Cipro and instructed to return to the clinic in five
days.

On her second post-op visit, the same symptoms and
exam findings were carried over into the review of systems.

However, the surgeon noted she would be ready to return
to work the following week. On her third post-op visit, she

saw another physician in the surgical practice. The EHR
again carried forward documentation of the skin, HEENT

assessment, and the complaints of drainage from her
incision, flank pain, fever, and frequency and urgency with

continued on following page

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