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Orthopaedic Clinic

Documentation pearls.

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Documentation is one of the most important part of any practice. what you put in a patients medical record could lead you to a law suit in a court ar drive you away from a potential litigation.
 
The biggest problem during any documentation is the lack of completness and thoroughness. Ensure that the document has physicians role, decision - making process and justifications for a given management approach.
 
Some general principles that need to be followed are:
  1. Patients name , medical record number, date of service.
  2. Co surgeons, assistant at surgery involved in the case.
  3. Pre and Post operative diagnoses supporting the medical necissity of any given procedure.
  4. Summary of the procedure performed and the technique used.
  5. Clinical Findings or intraoperative occurence that might have prolonged the surgery or increased the level of difficulty.
  6. Operative approach used.
  7. Area of the bone operated and mention different levels if applicable.
  8. Type of instrumentation used.
  9. Type of bone graft used.
  10. patient condition at the end of surgery.
  11. Estimated blood loss.
  12. Appropriate ICD - 9 CM codes.

Some Do's and Donot's of Documentation:

  1. Donot destroy any evidence.
  2. Do label any later additions in the record as late entries, include the date and time of the entry.
  3. Ensure that time and date are accurately entered in each of the records.
  4. Donot ever change the records.
  5. Do remember to include all of the positive findings and significant negative findings from the patient history and clinical examination.
  6. Do mention the relevant lab resultsand impact of those on your management strategy.
  7. Do describe the management in clear, concise and un ambigous form. Preferrably give a brief reason for choosing the particular strategy.
  8. Donot write in any personal comments.
  9. Never write any review about previous surgeons, colleague or comment about error in judgement or mangement commited by a colleague.

 

 

 

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