Writing is Rewriting or How I Avoided Going To Court By Effectively Documenting
Documenting the Patient History
This is a pretty good description of what has happened. This XX year old male/female
The most important aspect of effective documentation is the ability to tell a story of what happens so that there is a narrative before waveforms are looked at.
What we want to do is craft better paragraphs with important details ending the case with the baseline potentials were within normal limits with MEP and Sensory in all four extremities and showed no significant change from baseline during surgery. If there are changes during the surgery, for example there is a change of potentials in the lower left extremity, decrease in SEP and change in MEPs from tibialis anterior, weakness from stimulation, no response, etcetera, a reflection of notifying the surgeon, make an adjustment, if it comes back despite whatever interventions were done, notification of anesthesia, whatever interventions were taken and of course check the red box and make an alert
Event log documentation; I am a proponent for heavy event log documentation making some kind of comment every 15 minutes and clearly documenting anesthetic regimen, any changes and the patient's blood pressure/MAP. I begin documenting as soon as the patient comes into the room an allow the Event log to tell it's own story so that there are multiple layers of written communication that show that one is both paying attention and communicating accordingly with the online reader.
USMON Chat log is another layer of communication that can be referenced in court. Best to not have any personal communication on USMON chat and it is ideal to keep the online reader up to date with the progress of the surgery and notify them of any observed changes in potentials. I like to have my event log in view visible for them to follow along as i document the progress of the surgery. Each company may be different in the way they approach the online reader, however, I typically don't transfer my screen until incision is about to be made. I like to set up my electrodes, get a baseline if necessary, allow the patient to be put into position and then time-out. If you need some help it is probably best to connect with the online reader right away and discuss and review your plan for monitoring.
The complete story is, what are the baselines, what happened during the case and what's happened at the end. A good
Summary report
This is a pretty good description of what has happened. This XX year old male/female
The most important aspect of effective documentation is the ability to tell a story of what happens so that there is a narrative before waveforms are looked at.
What we want to do is craft better paragraphs with important details ending the case with the baseline potentials were within normal limits with MEP and Sensory in all four extremities and showed no significant change from baseline during surgery. If there are changes during the surgery, for example there is a change of potentials in the lower left extremity, decrease in SEP and change in MEPs from tibialis anterior, weakness from stimulation, no response, etcetera, a reflection of notifying the surgeon, make an adjustment, if it comes back despite whatever interventions were done, notification of anesthesia, whatever interventions were taken and of course check the red box and make an alert
Event log documentation; I am a proponent for heavy event log documentation making some kind of comment every 15 minutes and clearly documenting anesthetic regimen, any changes and the patient's blood pressure/MAP. I begin documenting as soon as the patient comes into the room an allow the Event log to tell it's own story so that there are multiple layers of written communication that show that one is both paying attention and communicating accordingly with the online reader.
USMON Chat log is another layer of communication that can be referenced in court. Best to not have any personal communication on USMON chat and it is ideal to keep the online reader up to date with the progress of the surgery and notify them of any observed changes in potentials. I like to have my event log in view visible for them to follow along as i document the progress of the surgery. Each company may be different in the way they approach the online reader, however, I typically don't transfer my screen until incision is about to be made. I like to set up my electrodes, get a baseline if necessary, allow the patient to be put into position and then time-out. If you need some help it is probably best to connect with the online reader right away and discuss and review your plan for monitoring.
The complete story is, what are the baselines, what happened during the case and what's happened at the end. A good
Summary report
The Surgeon's Perspective
Confidence in your game
Tactical empathy
how to break tough news
how to ask a question
how to talk with anesthesia
give context
what are the rules
chivalry
Confidence in your game
Tactical empathy
how to break tough news
how to ask a question
how to talk with anesthesia
give context
what are the rules
chivalry
- It is extremely important that audiologists and audiology graduate students make a concerted effort in documenting their clinical encounters, test results and recommendations and in maintaining patient records
- SOAP
- S - subjective information
- the patient's primary presenting complaints or symptoms; medical, otologic, audiological history and reason for the patient's visit
- relavent observations about the patient and his or her family may also be included in this section
- O - objective information
- tests, procedures or services performed together with their findings
- A - the assessment of the clinical encounter
- data obtained from the subjective and objective sections are synthesized to formulate a conclusion (diagnosis)
- data driven; same assessment should be reached by different audiologists if given the same subjective and objective information
- P - treatment or management plan
- recommendations regarding the next steps in the management of the patient
- recommendation for further testing
- follow-up
- referral
- recommendations regarding the next steps in the management of the patient
- S - subjective information
- The outcome of the clinical encounter should relate back to the plan, the plan should relate back to the assessment and the assessment should always relate back to the subjective and objective findings
Clinical Report Writing/Documentation Guidelines
Demographic Information; Patient Name, MRN, DOB, Age, Gender, etc
Procedure Information
Monitoring Specifics
Surgery Documentation
Anesthesia documentation
Baselines
Surgical States
Pedicle Screw Stimulation
Communication
Physician Order
TCMEP Documentation
Accuracy
Procedure Information
Monitoring Specifics
Surgery Documentation
Anesthesia documentation
Baselines
Surgical States
Pedicle Screw Stimulation
Communication
Physician Order
TCMEP Documentation
Accuracy