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 tennis match. But even these basic facts need to be notated with precise 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.
Indeed, incomplete documentation before an operation can mean that a patient’s preoperative surgical risks aren’t known, or can lead to serious errors like operating on the wrong knee. It can also increase the risk of inpatient-only denials, inconsistent OR case durations, and less-than-ideal reimbursements. By incorporating comprehensive clinical terminology and additional codes, like HCPCS, clinicians and surgical personnel can easily add the required level of specificity to optimize reimbursement and patient care.
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.
From patient safety to risk management to regulatory requirements and reimbursement, documentation plays a key role in all facets of the healthcare system.
