Page 40 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

Let’s review another case with several documentation and

process issues:

C A S E S T U DY

A 46-year-old female with history of COPD and chronic
pain underwent bilateral trigger point injections to her

back. She immediately complained of shortness of breath,
requiring assistance to her vehicle post-procedure.

Upon returning home, the patient developed bilateral
pneumothoraces from needle penetration, coded enroute

to the ER via EMS later that day. She was admitted to ICU
and ultimately expired.

The metadata showed that the physician made longer,

more precise chart notes four different times within an
hour or two of the clinic receiving a call from the hospital
about the patient being admitted to ICU. About 30 minutes

following the last physician entry, another staff member

changed several portions of the chart. This was reportedly
the usual course of business as vital signs were typically
written on a post-it note and entered into the EHR later.

Even worse, metadata showed someone “signed in as

the physician” the day after the event and modified entries
in the procedures, vitals, and medical history sections.
The physician denied having made those entries.

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