Page 34 - 2022 Risk Basics - Surgical Practice

SVMIC Risk Basics: Surgical Practice

CASE STUDY

A physician, over the course of several office visits,
incorrectly carried over erroneous documentation

suggesting a positive study for an enlarging lung mass,

which was the basis for a lobectomy. The post-op
pathology report revealed no such cancer. During the

deposition, the physician admitted to the documentation
errors that were the result of the copy and paste function

of the EHR system. While the physician’s failure to review

the study prior to taking the patient into surgery was
difficult to defend, the documentation errors called the

entire record, as well as the physician’s credibility, into
question.

In addition to preserving the record for continuity of care, your
documentation becomes a crucial component in defending

allegations of negligence. The record will usually take
precedence over memory of past events and is generally held

to be more objective and unbiased than your testimony since it
is written when your only obligation is to record the facts.

Systems

Systems issues, the third area of risk, were a factor in 18

percent of the paid surgical claims. Effective systems are the
bedrock of ensuring consistent physician and staff

performance. They help reduce adverse events and claims by
decreasing reliance on memory or informal mechanisms.

Page | 34