Page 33 - Part 1 Anesthesiology Common Risk Issues

SVMIC Anesthesiology: Common Risk Issues

Medical Record Alterations

If it is determined that a medical record has been altered, it will

call into question the physician’s integrity, and not only greatly
diminish the chance of prevailing in the medical malpractice

lawsuit, but also put professional liability coverage for the
incident at risk. It can also nullify the statute of limitations,

eliminate the statutory cap on damages in states that have
enacted tort reform, and serve as a basis for a punitive damages

claim. Never make a change in the medical record after
receiving notice of a claim or a lawsuit without first consulting

an SVMIC claims attorney.

Anesthesia Record

In addition to documentation issues with the pre-anesthesia

record, our claims review revealed a number of inadequate
documentation issues within the anesthesia record. Examples

of information that were missing include:

Details about emergency response/interventions: The lack
of documentation of cardiac arrest during a crisis, as well as

major inconsistencies with the operative record, allowed the
plaintiff to allege careless and improper emergency response.

Maneuvers utilized for managing a difficult airway: The
failure to document the events that unfolded in these cases,

or the maneuvers utilized, paved the road for the plaintiff to
allege negligent treatment and lack of attention to detail.

Anesthesiologist’s presence during induction/emergence:

The failure to document such led to allegation of improper
CRNA oversight in a number of claims.

Positioning and padding: Insufficient notes hampered the

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