How Your Clinical Documentation Methods Can Reduce Your Malpractice Liability Exposure

bigstock-Doctor-Banging-His-Head-Realiz-9513941Accurate electronic medical documentation is vital to patient safety, especially when it comes to avoiding surgical errors. Malpractice cases are in the news constantly, and there’s no shortage of articles that provide details about various surgical instruments left in patients after surgeries have been completed.

Being accused of malpractice costs physicians a significant amount of money each year. Some have even lost their practices or their licenses because of the mistakes they made in the operating room. Improved clinical documentation methods can dramatically reduce a physician’s malpractice liability exposure, and with the abundance of options that are available today, it is easy to make changes in this area.

One Woman’s Story

According to an article in Canadian Healthcare Technology, one woman had the foundation for a disturbing malpractice case when the surgeon who performed her double mastectomy left two rolls of gauze in her wound after the surgery was over. While it’s often standard procedure to leave gauze behind to help with bleeding as wounds heal, in this particular case, there was no documentation to suggest that the gauze was even present.

The fifty-two-year-old Canadian patient went home to recover instead of staying in the hospital, and she was provided with homecare during this time. A few days after returning home, she began experiencing a great deal of pain in her chest, and routine tests to determine the cause of the pain came back without answers. The patient even stated in no uncertain terms how painful the area was when she said, “It was extremely painful. I could hardly move. I’ve never felt so terrible in my life. … My whole right side just felt like it was on fire.”

She continued to receive homecare, and underwent several bouts of antibiotics because physicians assumed that infection must be the cause of her pain. Nothing helped, and so they planned to do another surgery.

What they found was startling to everyone in the operating room. Surgeons recovered two rotten rolls of gauze that left a gaping hole in the patient’s chest. They were unable to find any documentation regarding the gauze, and so home healthcare workers would not have realized it was even there so that it could be changed daily.

The Importance of Clinical Documentation

This patient’s case is definitely shocking, however instances such as these happen far too often. Had the surgeon who performed her first surgery provided the proper operative report, her problems and her pain would have been avoided. The staff who attended to her needs in her home would have known exactly how to care for her wounds. The problem is that many surgeons don’t use the newest available technology, which is designed to help them avoid these types of surgical errors.

Synoptic Reporting

Medical cases such as this one are prime examples of how synoptic reporting is beneficial in electronic medical documentation. Through the use of consistent terminology and configurable alerts, there’s never a concern that important factors in a patient’s care will be overlooked. It’s all too common for surgeons to leave vital information out of patient reports because so much is happening in the operating room, and because many of them don’t compile reports until the end of the day.

Perhaps you can relate, and you have your own concerns when it comes to reducing your own malpractice liability exposure. With all of the changes that can be made, improving clinical documentation methods is the best way to ensure that your level of care remains high and your risk of malpractice remains low.