Page 31 - 2022 Risk Basics - Anesthesiology

SVMIC Risk Basics: Anesthesiology

stay overnight and refuses, that refusal should be noted along

with instructions given to the patient for return as well as the
risk to the patient for refusal to stay. If not documented, it can

be inferred that the actual communication never took place.

An additional, although less frequent, documentation issue
uncovered in our claims review is untimely notes. Notes should

be completed the same day. There are hazards associated

with delayed documentation as memory can interfere with
accuracy, and any intervening event can make notes look self-

serving. Claims of erroneous documentation have been alleged

when the anesthesia record does not reflect what the
operative note reflects in terms of blood loss and fluid

administered, or when an anesthesiologist used a generic one-
page H&P combined with a discharge form, where the

discharge note was pre-dictated and never updated after an
adverse event.

An additional documentation issue found involves the

utilization of an EHR, which has its own benefits as well as
complexities regarding documentation.

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