Outpatient Surgery Magazine

Bring It On- December 2020 - S...

Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.

Issue link: http://magazine.outpatientsurgery.net/i/1316512

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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.

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