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Documentation


Document, document, document!

Who is responsible?


Everyone who provides care to a patient is responsible for documenting the care and recommendations that have been provided.

This can be delegated to an assigned recorder (for example, during an emergency resuscitation), but it is wise to confirm the accuracy of the record as soon as reasonably possible.

Case: Action not documented
Side view of male physician dictating a report

Background

A junior resident on a gynecology rotation assists at an abdominal hysterectomy. The staff surgeon points out the anatomical landmarks and the steps being taken to define and protect the ureters.

Following the procedure the student is told to dictate the operative report. The resident dictates a standard operative report using a template and does not mention the care taken to identify and protect the ureters.

Think about it

How might this approach to record keeping compromise the patient and the physicians in the future?

Outcome

The patient developed a post-op ureteral obstruction and later sued. When experts reviewed the operative report they found no reference to the steps taken to protect the ureters and they inferred that no such steps had been taken. Based on the documentation, surgical peer experts had difficulty supporting the surgeon.

Lessons learned

  • Even if good care has been given, incomplete documentation can give the opposite impression.
  • Templates may help in record keeping but should not preclude a comprehensive note specific to the individual patient.
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