Page 46 - OB Risks - Delivering the Goods (Part One)
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SVMIC Obstetrics Risks: Delivering the Goods
Breakdown of OB/GYN Documentation Issues
The largest problem area is inadequate documentation.
Examples in this category included: the physician’s failure to
document the management of shoulder dystocia; failure to
describe the rationale for choosing a laparoscopic procedure
over an open procedure; failure to document the decision to
either use, not to use, or adjust a Pitocin drip; and inadequate
documentation of the informed consent discussion process as
was previously outlined.
Although less common, untimely documentation can affect
the outcome of a lawsuit when the progress notes, operative
notes, or labor and delivery reports are documented several
days, or even weeks, after the date of service. In these cases,
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