The importance of documentation


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One of the important activities for any surgeon is the creation of an operative note. The traditional operative note should reflect the overall activities of the operation and should be a document that allows others to understand fully the events that occurred during this important patient event.
Sometimes we take for granted that the ability to dictate an operative note is a learned response and not innate for our surgical trainees or ourselves. The operative note has been scrutinized recently by a variety of nonclinical individuals who document specific codes and quality benchmarks. My concern is that the words that we have learned to use in our operative notes may be misinterpreted and may lead to significant penalties that will create unwanted issues as we seek recredentialing in our hospitals and reimbursement from payers.
Historically, many physicians have not put a great deal of energy into documentation within the medical record. This has been the case also in operative notes, which unfortunately may be dictated days, weeks or months after the specific event has occurred. While some have maintained this laissez-faire approach, government agencies and our legal system have taken strong stances regarding what we say and put down on paper documents and now in the electronic medical record. We have learned, sometimes the hard way, that if this documentation is not present, then it is not defensible and not reimbursable.
All of this change in reimbursement methodology, quality measure reporting and pay-for-performance has forced hospitals to pay attention to the quality of the written medical record. Hospitals are now taking a proactive approach to assure that clinical documentation not only reflects the events, but also is written in such a way that it cannot be a Damocles sword over us.
It is clear that the words that we use in our documentation will not be read only by our medical colleagues, and ourselves, but also will be scrutinized, interpreted and acted on by many individuals. Choosing words carefully as we dictate operative reports and other documentation must take a new and heightened importance.
One of the groups that we frequently hear about, but seldom see, are coders who generally reside in enclaves of our medical centers that are rarely visited. We have very little communication with these individuals, but I assure you they are very much involved in our daily activities and especially the oversight of our operative reports. There are certain requirements for conditions to be labeled “complications” by coders: 1) the condition must not have been expected or part of the clinical course; 2) the procedure/treatment provided directly has caused the given condition; and 3) the condition must be documented by the physician. Unless the complication is clearly indicated, the coder will use his or her best judgment regarding the wording in your document.
There are certain “red flags” that attract the attention of coders. We have appreciated that our colleagues in the legal profession have also looked for these flags. Terms such as “tear,” “laceration,” “puncture,” “hemorrhage” or “injured” raise red flags to those reviewing our documents. At times, we all have used these terms reflecting what we think is the best terminology in recording an operation. Who in our profession has not created an enterotomy? Even the term “enterotomy” is being re-evaluated by coders who may interpret the word as equating with a “puncture.”
We know that the creation of an enterotomy may be closely associated with a difficult dissection or adhesiolysis in a previously operated or radiated pelvis. Some would dictate: “The bowel was stuck together; a rent occurred as I separated the loops.” This could be rephrased: “The two loops of bowel had dense adhesions; I separated the loops by sharp dissection and created a partial (or full) thickness defect in one of the loops; this was closed by …” Although this may be seen by some as unnecessary wordiness, I assure you that the difference between a full, more-detailed description and the use of the words “rent” or “puncture” is worthy of your time and consideration.
Another possible dialogue in the operative record might be: “It became apparent that we had opened a hole in the rectum due to the adherence ….” This may be better characterized as: “The rectum and prostate were densely adhered to each other. In order to obtain adequate margins around the prostate, a portion of the anterior wall of the rectum was removed en bloc with the specimen.”
Our mission in using correct terminology is to be complete and not overly wordy. We must be clear and state the facts, especially if a complication occurs. My great concern, however, is that the terms that we traditionally use in our documents, especially our operative notes, are interpreted by others to be “complications” that will be used against us in documenting quality benchmarks and potentially recredentialing in our hospitals. For those of us in the academic world, an additional risk is having trainees document for us in the medical record. We must now take a more proactive approach of teaching our surgical residents and fellows the use of proper words that may not be misconstrued as we or they go forward.
In documenting postoperative events in the medical record, the use of the terms “fever,” “ileus” and “anemia” have been appropriate, but now are being looked at as potential complications even though we interpret an ileus after an abdominal procedure to be a recognized event. We must be clear that these are not complications, but part of the patient’s expected course.
The message is that we must document carefully and give additional thought as to how our words and phrases are interpreted by others. Common phraseology that we have used in the past may come back to haunt us. Think about what you are writing and dictating. Carefully explain what we mean by terms that were traditionally used, but now can be misunderstood by those non-physicians who are controlling our destiny.

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