Page 11 - 2022 Risk Basics - Anesthesiology

SVMIC Risk Basics: Anesthesiology

Documentation

The first category of indefensibility issue we will examine is

documentation. This issue is certainly not unique to anesthesia
and is the most common factor we see across all specialties

which makes cases indefensible. This remains true regardless

of whether an electronic health records (EHR) system or paper
charts are being used and despite repeated emphasis of the

importance of proper documentation through risk education

programs.

Effective documentation is one of the most important patient

care and risk management skills a healthcare professional can

develop. A quality medical record not only fosters effective
communication among members of the healthcare team, thus

promoting effective management of patient care, but also
serves as evidence of all pertinent facts associated with the

diagnosis and treatment of a patient. In the event of a medical
malpractice lawsuit, it becomes a crucial component in

defending allegations of negligence and may help establish

that the standard of care was met. It will likely take precedence
over memory of past events. The medical record is generally

held to be more objective, reliable, and unbiased than your

verbal testimony since it is written when your only obligation is
to record the facts. In almost every malpractice lawsuit, the

chart (whether electronic or paper) will be the most important
piece of physical evidence.

Now, let’s take a look at the breakdown of the issues in the

documentation category and their significance. Inadequate
documentation was identified in a majority of those cases as a

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