Page 39 - Part One Risk Reduction Series - Documentation
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SVMIC Risk Reduction Series: Documentation
CASE STUDY
A 46-year-old female with history of COPD and chronic pain
underwent bilateral trigger point injections to her back. She
immediately complained of shortness of breath, requiring
assistance to her vehicle post-procedure. Upon returning home,
the patient developed bilateral pneumothoraces from needle
penetration, coded in route to the ER via EMS later that day. She
was admitted to ICU and ultimately expired.
The metadata showed that the physician made longer, more
precise chart notes four different times within an hour or two of
the clinic receiving a call from the hospital about the patient
being admitted to ICU. About 30 minutes following the last
physician entry, another staff member changed several portions
of the chart. This was reportedly the usual course of business as
vital signs were typically written on a post-it note and entered
into the EHR later. Even worse, metadata showed someone
“signed in as the physician” the day after the event and modified
entries in the procedures, vitals and medical history sections. The
physician denied having made those entries.
This case highlights the need for contemporaneous
documentation, ensuring anyone authorized to make entries into
the EHR have his or her own individual access and serves as a
caution against making entries following notification of an adverse
outcome.
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