Page 59 - OB Risks - Delivering the Goods (Part One)

SVMIC Obstetrics Risks: Delivering the Goods

Each encounter with a patient must be documented

appropriately. All treatment given, subjective comments or
complaints, response to treatment, and patient progress should

be clearly explained in the medical record. As a guideline for
defining the levels and components for coordination of care,

the examination/assessment should include information that is
obtained, gathered, and documented by the physician, based on

clinical judgment and the nature of the presenting problem(s).
When using a prenatal flowsheet, free text or other comments

regarding pertinent abnormal test results or observations should
be included.

Records should be prepared as contemporaneously with

treatment as possible in order to avoid confusion and help
ensure validity. Entries should appear in chronological order,

and each entry should be signed and dated. The physician
should sign and date all lab, x‐ray, and consultant reports after

reviewing, or the electronic system should automatically date-
stamp these documents after the physician completes the

review.

When documenting a patient encounter, it is helpful to use

a consistent format such as SOAP, which will help to outline
a carefully thought-out diagnosis and treatment plan. Keep

in mind, if the office visit documentation is not legible, clear,
and accurate, the diagnosis and treatment plan are useless.

A misplaced decimal point or the inadvertent use of a wrong
term has resulted in grave medical error. Physicians should be

meticulous in charting drug names, doses, and regimens.

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