Why getting surgical documentation right matters

When it comes to surgery, if something isn’t documented in a patient’s chart it’s as though it didn’t happen. Even the most basic facts of a case must be recorded with the correct clinical terminology in order to ensure high-quality care. And it’s not just the operative note that’s important – excellent documentation is needed at all stages of a patient’s surgical care.
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Clinical Terminology

When you’re a patient in need of surgical care, certain things probably seem obvious. Your left knee needs replacing, not your right; you were injured in a car accident, not during a sports game. But even these basic facts need to be notated with EHR terminology and placed in your medical problem list in order for your procedure to go according to plan.

And, once in the operating room, subsequent documentation becomes even more critical. A surgeon’s operative note serves as a medical record, legal document, billing resource, and – most importantly – the nuanced details of a patient’s story. It’s a big deal for everyone if anything is omitted or inaccurate, especially when it comes to patient safety.

Indeed, incomplete documentation before an operation can mean that a patient’s preoperative surgical risks aren’t known, or it can lead to major errors like operating on the wrong knee. But within the perioperative space – the time during and immediately after surgery – it’s also imperative that any deviations from a surgical plan are recorded. While it’s easy to assume these changes would be notated, it’s actually one of the pitfalls of using the auto-populate feature or a generic template form when detailing a surgical procedure. Without updates to prewritten text, those caring for the patient after surgery may not know that additional precautions or attention – like administering specific medicines, or monitoring more frequently – are warranted to ensure optimal outcomes.

And the value of good notes doesn’t end there. From patient safety, to risk management, to regulatory requirements, to billing and reimbursement, documentation plays a key role in so many parts of the healthcare system. Learn more about how patient records influence a surgical department’s ability to deliver high-quality, efficient, and cost-effective care from Janice Kelly, President of AORN Syntegrity and IMO experts in our on-demand webinar, Getting surgical documentation right: A fireside chat.

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