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"I'd like a copy of my wife's sedation record, please."

By: Henrik Joreteg

Published: 12/9/2022

When you read the phrase, "I'd like a copy of my sedation records, please," does your heart beat faster? You're not alone.

We estimate that roughly ~90% of anesthesia cases outside large hospital settings are documented as handwritten, sloppy copies of anesthesia paperwork. The anesthesia profession has continued to evolve to make the patient experience more comfortable and safe. Shouldn't our charting provide the same excellence and professionalism?

If you're reading this, you've likely invested countless hours and dollars getting to a place where you could offer safe anesthesia for your patients. You've had hundreds, maybe thousands of happy patients walk in and out your doors.

Then, one fateful day, something goes wrong...

Fortunately, the patient is okay, but there were some complications. You were shaken when your patient started to desaturate quickly. You remembered your training and successfully resolved the issue

In post-op, you tried to remain composed, but the patient's sister, who was driving her home, could tell something was off.

A few days passed, and you moved on. Unfortunately, it seemed like the patient and her family has some lingering concerns about what happened that day, and they want answers. The patient's husband, who happens to be a surgical nurse, comes to your office and demands a copy of his wife's sedation record.

How are you feeling now?

The details have been changed, but this scenario is not made up. One of our customers told us this story. They had a concerned spouse come in demanding records a few days after their procedure. To be clear, it's not that adverse events can't happen. Of course they can! The problem occurs when you can't provide a thorough, detailed, legible, and truthful record.

All the training, money, and thousands of happy clients won't help you much if you're handing over a messy, handwritten sheet of paper with a bunch of hand-drawn chevrons in a perfect train-track pattern. No one is going to be impressed by that.

Thankfully, this provider was an Xchart customer. He simply pulled up the patient's anesthesia record on his computer and printed off a copy, confidently handing it to the spouse. The situation was resolved quickly and efficiently.

We're judged by our worst days, not our best.

I'm reminded of what Dr. Richard Mounce said during our podcast with him on The Dental Clinical Companion:

"I do a fair bit of expert witness work, and you mentioned illegible handwriting, and suffice it to say that I have seen a strong correlation between malpractice claims and handwritten records. I would say, probably a half to two-thirds of the cases that come across my desk don't have digital records." - Dr. Richard Mounce

So, when faced with a scenario like this, you tell me which documentation you would rather hand over, a thorough, detailed, legible, and truthful document or a sloppy copy.

With Xchart, it's never been easier to automatically monitor vitals, track drugs administered, and generate a clean PDF to comply with documentation requirements.

From general anesthesia to minimal sedation, if you do anesthesia in an office or surgery center, we've got you covered.

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