by Olga Maystruk, Designer and Brand Strategist, and
Jennifer Templin, Risk Management Representative
Presentation and physician action
A 63-year-old man came to Ophthalmologist A for treatment of sagging upper and lower eyelids. Upon examination, the physician recommended a blepharoplasty to correct the condition.
Three months later, on September 5, Ophthalmologist A performed the upper and lower eyelid surgery. During a follow-up appointment on September 10, the physician noted a right-side lower lid laceration that was then stitched.
One week later, the patient returned for the removal of stitches. During that visit, Ophthalmologist A noted laxity and recommended a canthoplasty to tighten the right eyelid.
On October 9, the patient went to a plastic surgeon about a scar on the right lower eyelid and cheek area. The patient claimed he had been burned by a laser during the blepharoplasty. The plastic surgeon recommended a scar revision and bilateral lid surgery for asymmetry.
On November 5, the patient consulted with Ophthalmologist B about the scar revision. Ophthalmologist B recommended a second blepharoplasty followed by the scar revision surgery to be performed by a plastic surgeon.
On December 1, Ophthalmologist B performed bilateral lid surgery. Nine months later, the plastic surgeon performed the scar revision surgery.
Allegations
The patient filed a lawsuit against Ophthalmologist A alleging improper performance of a blepharoplasty resulting in a scar below the right eye.
Legal implications
Ophthalmologist A and the patient presented different versions of what occurred during and after the blepharoplasty. The patient claimed the burn on his face was caused by a laser, while Ophthalmologist A reported using an electrosurgical device (a bovie) to make the incision. Ophthalmologist A could not recall the injury or its repair. However, there was evidence of a burn and subsequent repair with sutures.
The operative report for the lower lid procedure and notes from the follow-up visit were missing; there was no official record of what instruments were used during the procedure or how the injury occurred. The experts for the defense agreed that the lack of documentation presented a major weakness in the defense of this case.
Disposition
The case was settled on behalf of Ophthalmologist A.
Risk management considerations
In this case, there was an issue of miscommunication with the patient. From the case documents, it appeared the patient was under the impression that his blepharoplasty included the use of lasers. While there are providers who do use lasers for this procedure, Ophthalmologist A maintained that he did not use a laser on this patient. However, the patient’s injuries suggest otherwise.
According to the Centers for Medicare and Medicaid Services, “documenting each patient encounter completely, accurately, and on time” is vital to providing and coordinating quality medical services.1
Ophthalmologist A did not adequately document the blepharoplasty, as the patient record was missing both the operative notes for the blepharoplasty on the lower lid and documentation of the subsequent injury. Additionally, the documentation did not mention which instruments were used.
As with any surgical procedure, it is the physician’s responsibility to conduct an informed consent discussion with a patient to answer questions and fully explain the procedure. This discussion must also include the risks and benefits of the procedure and any other treatment options. It is important to educate the patient about specific treatments and/or interventional procedures so that the patient understands what to expect.
Source
- Centers for Medicare and Medicaid Services. Documentation Matters Toolkit. Last updated September 6, 2023. Available at https://www.cms.gov/medicare/medicaid-coordination/states/dcoumentation-matters-toolkit. Accessed July 9, 2024.
Olga Maystruk can be reached at olga-maystruk@tmlt.org.
Jennifer Templin can be reached at jennifer-templin@tmlt.org.
