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Documenting Suspension of Elective and Non-Urgent Procedures and Surgeries

On March 20, 2020, the North Carolina’s Secretary of the Department of Health and Human Services requested that effective March 23, 2020, all hospitals and ambulatory surgery centers suspend all elective and non-urgent procedures and surgeries in an effort to conserve personal protective equipment and other equipment and supplies needed by frontline healthcare providers to treat COVID-19 patients. See a copy of Dr. Mandy Cohen’s letter here. Elective and non-urgent procedures and surgeries are defined as any procedure or surgery that if not done within the next 4 weeks would cause harm to the patient. As a result, hospitals and ambulatory surgery centers have been asked to perform a real-time review of scheduled procedures and take into account the patient’s best interest as well as the health and safety of other patients and the public. In making this determination, providers need to properly document in a patient’s chart that this review has been conducted and the rationale for postponing or cancelling a procedure or surgery. It is also important to document in the chart whether or not the patient agrees with the provider’s decision. Here are some examples of how to properly document:

Postponed/Canceled at the Patient’s Request

 

Patient’s Decision and the Doctor Agrees

This decision is appropriate and reasonable under the circumstances given my understanding of the patient’s particular circumstances at this time. While I do not believe that that the patient will be harmed by this postponement/delay, the patient has been advised of the potential risks of this decision and has agreed to postpone/delay the procedure/surgery. Any and all of the patient’s/patient’s family’s questions on this issue have been answered, and I have made no promises or guarantees to the patient regarding the effects of this postponement/delay. The patient has also been advised to contact this office for worsening conditions or problems, and seek emergency medical treatment and/or call 911 if the patient deems either necessary.

Patient’s Decision and Doctor’s Recommendation is Contrary 

Taking into account all circumstances, I recommended the procedure/surgery go forward given my understanding of the patient’s particular circumstances at this time. I believe that that the patient will be harmed by any postponement/delay and the patient has been advised of the potential risks of postponement/delay which are not limited to but may include: ______.  Any and all of the patient’s/patient’s family’s questions on this issue have been answered, and I have made no promises or guarantees to the patient regarding the effects of this postponement/delay. The patient has also been advised to contact this office for worsening conditions or problems, and seek emergency medical treatment and/or call 911 if the patient deems either necessary.

 Postponed/Canceled as a Result of Physician’s Recommendation

This patient’s procedure/surgery is elective and non-urgent.  Elective and non-urgent surgeries have been defined by the Secretary of the NCDHHS as any procedure or surgery that if not done within the next 4 weeks would not cause harm to the patient.  This decision is appropriate and reasonable under the circumstances given my understanding of the patient’s particular circumstances at this time.  While I do not believe that that the patient will be harmed by this postponement/delay, the patient has been advised of the potential risks of postponement/delay and has agreed. Any and all of the patient’s/patient’s family’s questions on this issue have been answered, and I have made no promises or guarantees to the patient. The patient has also been advised to contact this office for worsening conditions or problems, and seek emergency medical treatment and/or call 911 if the patient deems either necessary.

Please visit our COVID-19 Resource Center for more information related to the Coronavirus outbreak.


Elizabeth P. McCullough advises and defends health care providers in matters involving patient care issues and risk management issues. This includes representing clients in medical malpractice cases and educating and advising them in matters pertaining to EMR, supervision of mid-level providers, compliance issues and HIPAA, HITECH and other security issues.

Contact Elizabeth at Elizabeth.McCullough@youngmoorelaw.com or (919) 861-5071.


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