2 2 • O U T P A T I E N T S U R G E R Y M A G A Z I N E • D E C E M B E R 2 0 2 0
Y
ou do countless things over the course of a
case to ensure a successful outcome, but
often don't think to include them in the
patient's chart because, well, they seem like rou-
tine tasks. That's fine — until there's a problem. If
complications occur or mistakes happen and your
facility gets sued, clear and accurate charting
could help you avoid legal trouble. Here are five
ways to ensure documenting is always completed
and done properly.
Respect the process
You're constantly under the gun to complete
cases, turn over the room and get the next case
started. Completing the patient's chart might not
seem like a priority, especially if the procedure was
routine and you performed tasks you've done thou-
sands of times before. But there's a reason why we
chart. It's to tell the story about the reasonable care
provided to the patient. While it might seem like the
least important and most tedious task before you at
1
Documentation is Never an Afterthought
Real-time records present the facts if a case ends up in a courtroom.
Medical Malpractice
William Duffy, RN, MJ, CNOR, FAAA
DULY NOTED Recording the steps you took to provide good patient care in an electronic health record can make all the difference in a lawsuit.
