Documentation Update Focusing on Delayed Procedures

During this pandemic, with the changes in healthcare such as the expedited emergence of Telehealth, virtual appointments and patients receiving care while remaining at home, accurate and precise documentation can be extremely beneficial.  Due to the COVID-19 pandemic, postponement of elective surgeries and non-emergent medical procedures has occurred and patients delayed various procedures or tests.  In the event that a provider has had a patient who postponed a procedure and/or test, documentation of the conversation as well as the plan of care is extremely important in preventing litigation. 

When speaking of routine surveillance procedures such as yearly eye exams, once-every-5 year colonoscopy it is still recommended to document in terms of re-scheduling (which presumably would be on a hard copy schedule) and that only emergent/urgent procedures were completed during this time. However, this is not the main area of concern.  Specifically, detailed documentation is more crucial with the management of the patient with a known disease and procedures such as gall bladder surgery.  If the patient had the surgery postponed due to the pandemic but was hospitalized and needed emergent surgery, accurate and precise documentation in this scenario would be favorable.

Equally as  important, if delaying a procedure or test carries a risk that a patient’s known medical condition may worsen, the provider should document that the procedure or test was unavoidably delayed and that the patient was advised about maintaining vigilance for and reporting to the provider about any changes in condition that would indicate disease progression. 

Accurate and timely documentation is beneficial, especially when attempting to recall specific conversations and/or incidents that took place days, months or years prior to possible litigation.  If you need to write an addendum, that is acceptable, however, it is more favorable to document in real time.