Your office staff is hyper-efficient. They know you perform outpatient surgery and see your patients the next day in the office. Never fail, they prepare the chart in advance, hang it in the door, with the date stamped on the page on which you will write.
One patient has an intraoperative complication. She develops a pneumothorax. No need for a chest tube. Patient is observed and goes home. Back in the office on post-op day number three. The chart is waiting for you.
Here's the problem. Your hyper-efficient staff had already date stamped the chart - expecting the patient to be seen the first post-operative day. There's a two day gap between the date stamp and the entry of your notes.
If you write a note that fails to correspond to the date, you will have, as Desi Arnez used to say, "some 'splaining to do." A plaintiff's attorney may try to make the case you altered records. Yada yada.
What to do? Feel free to write your note. Just label the note: "DELAYED ENTRY" followed by the current date. Sounds simple enough.
If you've got a hyper-efficient office, just be aware that such efficiencies can, on rare occasion, feed the alligators.
Medical Justice: Providing protection against hungry alligators.
