Page 32 - Part 1 Anesthesiology Common Risk Issues

SVMIC Anesthesiology: Common Risk Issues

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.

CASE STUDY

In one case example, two templates were opened on the

same patient for a procedure - one in the Endoscopy

lab well in advance of the patient’s arrival and the other
when the case was changed to same-day surgery. Both
templates were pre-populated with information to include

medications and doses usually administered, but only one,

the same-day surgery template, had the actual medications
used and events that occurred. When the patient suffered
a profound neurologic injury postoperatively, a lawsuit was

filed alleging that the types and doses

of anesthetic medications given were
inappropriate and that there was a failure
to monitor the patient which caused the

neurological injury.

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