Page 14 - Part 1 Anesthesiology Common Risk Issues

SVMIC Anesthesiology: Common Risk Issues

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 was written when your only obligation was 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 key reason for indefensibility. Other documentation-related

issues were illegible documentation, erroneous entries, late or
untimely notations, apparent alterations of the chart, and EHR

issues.

The American Association of Anesthesiologists has divided each

anesthetic procedure into three primary stages or categories:

• Pre-anesthesia

• Intra-operative/intra-procedural anesthesia

• Post-anesthesia care

The anesthesiologist/CRNA should accurately document each

of these stages/categories of an anesthetic procedure. From

a risk standpoint, claims and lawsuits can arise during each
of these three phases; therefore, careful attention must be
given to fully documenting each appropriately. Regardless of

whether you are using paper or electronic records, accuracy and

timeliness are of paramount importance.

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