Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.
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the moment, it truly is your best weapon for defense against mal- practice claims. Juries believe that people will lie and embellish their stories to make themselves look better. They don't, however, question docu- ments that were written at the time of the care before the lawsuit was filed. They view it as the real story you wrote down at a time when there was no reason for you to lie. It's best to always make note of your good work. Don't cut corners Resist the urge to pre-chart, even if you know you'll be busy later, you know what the surgery is going to be like and you want to save a couple min- utes by documenting ahead of time that something was done. This is a less hazardous practice with paper charts, because no one knows when notes are written, but every entry in electronic medical records is time-stamped. Don't put yourself in a posi- tion of having to explain to a jury how you noted at 7 a.m. that the patient came out of their surgery with no pressure injuries when in fact the procedure did- n't begin until 7:15 am. Even if that aspect of the case doesn't have anything to do with why the patient is suing, inconsistencies in charting will put all the testimony from your side into question. Create templates Whether it's cataract, arthroscopy or another procedure, there are things you know are going to happen during surgery. You can create a template that prepopulates standard aspects of patient care such as the position a patient will be in and what steps you took to prevent complications, such as put- ting a device on a leg to prevent thrombosis. That way, you only have to note or input a few variables, or correct changes that occurred to the routine flow of the case. Then, when you file the record, the time stamps will be coordinated to the end of the case. Templates, which are a great compromise between nurses who claim to not have enough time to chart and administrators who demand thorough documentation, should include the standard aspects of the case. This is similar to what individual sur- geons do with established order sets. The orders are preset, and surgeons can deselect orders they don't want for individual patients. Do the same with your electronic forms. Creating preset elements for things such as patient positioning means you have to edit the form only when changes are made to routine care. Having preset elements in place helps at the end of procedures, when your focus shifts to preparing for the next case and you might miss completing aspects of the chart. Tell your story Include a comment box in a template where you can note additional measures you took to make the patient comfortable and safe. For example, record that you provided padding for a patient with contractures or comforted a patient with autism. Juries are looking for reasonability and want to see that you cared about the patient's well-being. The extra things you did might not seem noteworthy to fellow surgical professionals, but could be what shows a jury that you really cared about the patient as a human being. Often, that can't be communicat- ed by checked boxes on a form. You don't have to be verbose about the additional care you provided, by the way. In the case of the patient with the con- tractures, for example, simply note, "positioning pads applied." This phrase can support testimony that you acted to protect your patient. Understand the importance Charting provides the opportunity to tell the story of the care you provided in the event of a legal dispute. It can also protect you and your organiza- tion from being liable for someone else's negli- gence. You might need to rely on your charting for back-up only occasionally, but when that need aris- es, it will provide crucial information that can tip the scales of justice in your favor. OSM Mr. Duffy (dodger6967@gmail.com) is the director of the Health Systems Management MSN program at Loyola University's Marcella Niehoff School of Nursing. 5 3 4 2 D E C E M B E R 2 0 2 0 • O U T P A T I E N T S U R G E R Y . N E T • 2 3 "Charts provide the opportunity to tell the story of the care you provided."