Documentation Question?

Havin' A Party!, ASN, RN · Dec 2, 2005

Think that might depend on the reason(s) for the delay.

What happened?

druse · Dec 2, 2005

Usually this occurs during the first case of the day. Say it's a 7:30 case and the delay is related to the surgeon not arriving on time.

Editorial Team / Admin · Dec 2, 2005

I have been asked about ramifications regarding the documentation of a delay being on an intra-op patient record. Our intra-op record has a field for documenting delay of case and reasons for the delay. A nurse has asked if this has any legal ramifications of permanently being part of the record. Would there be any liability to the nurse when the case is delayed from it's original start time?

Hello, druse,:balloons:

It will really depend upon why the case was delayed. Also, if it was an emergent case that was delayed. Many, many factors involved. If the surgeon was late and the patient was harmed, then yes, there would most probably be ramifications: litigation.

As for wondering if it should be in the MR, yes, definitely. If there is harm in any degree, you would want to see a rationale for the delay. If the entity involved has created a form for documentation of any delay, then this becomes part of the MR until administration culls the form.

As for the nurse being held liable, if the case is delayed due to any action, passive or active, or lack there of, then yes again, the nurse can/could be held liable.

Editorial Team / Admin · Dec 2, 2005

I might add.........

If the entity actively utilized in the past, a form for documentation of delay and decided to discontinue the use thereof, an astute legal nurse consultant/attorney could discover this and bring up why the form was no longer utilized. Bringing into focus the possiblilty of cover-up. Kinda far fetched maybe, but, hey, stranger things, right???

Havin' A Party!, ASN, RN · Dec 3, 2005

... Say it's a 7:30 case and the delay is related to the surgeon not arriving on time.

Again, to me, it still all depends on the specifics of the situation.

Maybe a way to generalize arround the details would be to say that if the RN failed to take reasonably prudent actions based on standards of practice in effect, or if she took unreasonable ones in the course of the case, then she might be found culpable. (But please see below.)

Further, it's not indicated whether any damages resulted to the patient from the delay. Despite that, there may be regulatory issues involved based on the "faulty" documentation. But then that brings me right back to the beginning of this message.

druse · Dec 3, 2005

The documentation of delay on the record is primarily used for QI for the surgical department, with the goal to improve efficiency of service. Every surgical department that I have worked at thus far in my career has collected this data to study start times, and turnover times of cases. Is this standard practice? To have accurate information, there would be need for rationale to explain a delay when it occurs. I would also think that in the case of a delay, if there were documentation, it would be more of an asset to the nurse. Delays are documented in relation to:

Previous case ran over

Surgeon

Anesthesia

Equipment

OR Staff

Complex case setup

Other

There is an area for explanation of rationale related to the delay.

Havin' A Party!, ASN, RN · Dec 3, 2005

Hello again, Druse.

OK, let's presume that:

1) No negative consequences resulted to the client and no one from his camp is complaining about the surgery or the delay;

2) The documentation in question is strictly a QI form developed in-house to track departmental efficiency (i.e., number / time of delays, responsible parties / sections, commonly recurring reasons, types of complex procedures causing delays, etc.);

3) The documentation is not required by any regulatory body having jurisdiction over the medical facility (e.g., JCAHO, a local, state or federal agency, etc.); and

4) It is the RN's duty, based on her job description, to complete the form accurately and timely, and to file it as instructed.

Under the above conditions, I see no "liability" for the RN. However, her employer (whether it be the hospital or an agency) may have a beef about her performance. Accordingly, it may take whatever action it deems appropriate if the RN isn't fulfilling her recordkeeping responsibilities.

yoga crna · Dec 17, 2005

Being an iconoclast, I would like to offer a different perspective of documenting delays in the operating room.

The PRIMARY purpose of the medical record is the care of the patient. What is documented is utilization of information that would lead to subsequent care or to determine what was done for and to the patient. It is a legal document, but that is not its primary purpose. Nor is the purpose of the medical record documentation of personnel issues or for billing reasons.

I would bet that the powers to be who want delays in surgery documented want them for financial audits or to chastise the surgeons, anesthetists or OR personnel for slowing down the schedule. There is no way these reasons have anything to do with patient care. If the delay was due to equipment malfunction or some other unforseen issue during the procedure, a notation would be appropriate. If the delay was due to the surgeon taking a lunch break prior to the patient being anesthetized, that would be inappropriate documentation.

I own a surgery center and know that time is money and do want to know about delays. But I have the nurses document times and any unusual delays on a billing sheet which is not part of the medical record. I use it when performing my income/expense analysis, but only have it on the medical record when it is a patient care issue, such as prolonged emergence from anesthesia.

What I do is not what is not necessarily done in large institutions. I really want my nurses to do nursing care and try to keep documentation down to what is really important and necessary. It works for my small surgery center.

Yoga CRNA