February 23, 2017

QUESTION:        One of our busiest general surgeons is chronically late in dictating her operative reports.  She often does not dictate the complete operative report until days or weeks later.  We are concerned about patient care and compliance with accreditation standards.  And we are expending unnecessary resources sending constant reminders. We think our rules and regulations are clear.  What can we do?

ANSWER:            You are correct that a surgeon’s failure to timely complete an operative report has patient care and compliance implications.  It is difficult to imagine how an accurate operative report can be dictated days or weeks after the procedure, especially when the surgeon has a busy practice.  That is why the issue of operative reports is addressed both in the Conditions of Participation and the Joint Commission Standards.

According to §482.51(b)(6) of the Conditions of Participation: “An operative report describing techniques, findings, and tissues removed or altered must be written or dictated immediately following surgery and signed by the surgeon.”  Joint Commission RC.02.01.03 Element of Performance 5 requires: “An operative or other high-risk procedure report is written or dictated upon completion of the operative or other high-risk procedure and before the patient is transferred to the next level of care.” There is an exception to this requirement when an operative progress note is written immediately after the procedure, in which case the full report can be written or dictated within a time frame defined by the hospital.

In dealing with your particular situation, we recommend, as a first step, that you gather information about the surgeon’s non-compliance with your standards, including any reminder letters that have been sent within the last year.  Share this with the Leadership Council (typically the Chief Medical Officer, the Chief of Staff, the Chair of the Credentials Committee and the Chair of the Peer Review Committee) and the Chair of the Department of Surgery.  Then invite the surgeon to meet with the Leadership Council.

In advance of the meeting, the Leadership Council can outline a proposed Performance Improvement Plan, including specific expectations and consequences.  For example, the Performance Improvement Plan may provide:

You acknowledge and agree that an operative progress note must be entered into the medical record immediately after surgery and before the patient is transferred to the next level of care.  This progress note must include the following:  the names of the physician(s) and physician assistants, procedure performed, findings, estimated blood loss, specimens removed, and post?operative diagnosis.

You acknowledge and agree that a complete operative report must be dictated within 24 hours of the surgery/procedure.

You may want to consider a course on medical record documentation and mentoring sessions to further help the surgeon correct the underlying issues.

Some medical staffs have had success in gaining compliance with medical record requirements by imposing fines for non-compliance. Other medical staffs use the concept of automatic relinquishment.  Both approaches can be progressive with each subsequent incident of non?compliance leading to higher fines and/or longer periods of relinquishment of appointment and privileges.