Page 32 - 2022 Risk Basics - Surgical Practice

SVMIC Risk Basics: Surgical Practice

issues, 33 percent were the result of untimely or delayed

documentation while 47 percent were related to inadequate or
omitted documentation. The remaining categories include

illegible documentation, EHR issues, erroneous

documentation, apparent alterations, 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.

In addition to untimely documentation, inadequate or omitted

documentation was seen in 47 percent of the claims reviewed.
Examples of inadequate documentation include:

 Incomplete preoperative patient histories

 Insufficient information to outline treatment rationale or
surgical decisions

 Sparse/lacking documentation of the 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 (with patients,
physicians, nurses, etc). Every clinical encounter should

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