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SVMIC Risk Basics: Surgical Practice
Documentation
The next area of risk issues identified in the claims review is
documentation. We have already covered documenting the
informed consent process. Likewise, 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 34 percent of claims
paid among surgeons. Of those claims with documentation
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