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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:
- Patients name , medical record number, date of service.
- Co surgeons, assistant at surgery involved in the case.
- Pre and Post operative diagnoses supporting the medical necissity of any given procedure.
- Summary of the procedure performed and the technique used.
- Clinical Findings or intraoperative occurence that might have prolonged the surgery or increased the level of difficulty.
- Operative approach used.
- Area of the bone operated and mention different levels if applicable.
- Type of instrumentation used.
- Type of bone graft used.
- patient condition at the end of surgery.
- Estimated blood loss.
- Appropriate ICD - 9 CM codes.
Some Do's and Donot's of Documentation:
- Donot destroy any evidence.
- Do label any later additions in the record as late entries, include the date and time of the entry.
- Ensure that time and date are accurately entered in each of the records.
- Donot ever change the records.
- Do remember to include all of the positive findings and significant negative findings from the patient history and clinical
examination.
- Do mention the relevant lab resultsand impact of those on your management strategy.
- Do describe the management in clear, concise and un ambigous form. Preferrably give a brief reason for choosing the particular
strategy.
- Donot write in any personal comments.
- Never write any review about previous surgeons, colleague or comment about error in judgement or mangement commited by
a colleague.
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