Risk Management for General Surgeons

Reducing risk in surgical practice involves creating and maintaining robust systems for informed consent, patient tracking, and documentation. This page outlines key considerations for surgeons in these critical areas, providing practical strategies to enhance patient safety and minimize liability risks.

Informed consent

An effective surgical informed consent process means the surgeon must disclose to the patient the most common inherent risks of the treatment that could influence a reasonable person in making an informed decision to accept or refuse that treatment.

While consents are often signed at the hospital or surgical center the day of the procedure, it is prudent for the surgeon and patient to discuss the potential risks and complications well in advance of the procedure if possible. The office environment is conducive to the question-and-answer period necessary to provide informed consent. When consent is obtained in the office, the argument can be made that the patient had adequate time to review and understand risks, benefits, and alternatives of treatment.

• The surgeon performing the procedure, not a delegated representative, is responsible for making sure that the patient gives informed consent.
• The informed consent discussion— including the risks, benefits, and alternatives to the surgery or procedure — should be documented in the medical record.
• When obtaining consent, use descriptive, non-medical terms to ensure patients understand complicated procedures. A good practice is to use key repetitive phrases, and ask patients to repeat what you have said.
• If there is a possibility that a procedure might need to be changed during surgery (for example, from a laparoscopic to an open procedure), be sure this is included in the consent forms and discussed with the patient.
• If others, such as family or friends, are with the patient during the informed consent discussion, document their presence in the patient’s record.
• If the patient declines surgery or other treatment, document their refusal, the discussion you had outlining risks of refusing care and any alternative treatments available. At your discretion, depending on the perceived risk of the patient declining care, you may wish to consider having them sign an informed refusal of care document.

Some states have rules and regulations regarding informed consent for procedures. For example, in Texas, informed consent is governed by statute and is overseen by the Texas Medical Disclosure Panel (TMDP). The panel includes physicians and attorneys who determine which procedures require informed consent and which do not. Procedures and treatments are then assigned to those requiring disclosure of specific risks and benefits (List A), or those that do not require disclosure of risks (List B).

The TMDP also develops specific disclosure and consent forms to be used by Texas physicians. The lists, TMDP rules, and forms can be viewed here.

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Tracking and follow up

Having reliable tracking and follow-up systems is crucial for managing patients before and after surgery. When referring patients to consultants or sending them for lab or diagnostic tests to obtain surgical clearance, use a tracking system to ensure the patient was seen, tests performed, and results received.

Tracking systems vary from practice to practice based on needs and available resources. Yet, the basic steps for managing patient test results and consults remain the same:

1. Track tests and consults until results are received.
2. Review the results and recommendations before they are added to the patient’s record, or make sure all results are on regularly checked “pending” review lists in the EMR.
3. Notify patients of the results and document that notification occurred.
4. When needed, ensure these results are communicated to other treating physicians so the patient can receive the recommended follow-up care.

The preoperative period is also an ideal time to determine and document who will manage medications that must be stopped before and resumed after surgery (such as anticoagulants). This includes who will monitor any symptoms patients experience during this interruption.

Pre-surgical appointments provide an opportunity to address areas of concern. Reviewing the patient's previous visit notes, medications (including supplements), and laboratory and diagnostic results can help promote optimal surgical outcomes.

These appointments also serve as crucial opportunities to discuss the patient’s expectations, provide detailed pre-operative instructions, and address any questions or anxieties about the procedure.

Care and attention to transitioning the patient safely out of the hospital or surgical facility are critical. Consider these additional risk management strategies.

• Patients may be more susceptible to medical errors during the transition of care between inpatient and outpatient settings. Surgeons are encouraged to consistently communicate with the outpatient providers, particularly if there is critical information that could affect the patient’s care.
• Document any discussions with consulting physicians and hospital/surgical center staff about a patient’s test results, treatment, and recommendations.
• If patients experience complications, carefully document any deviation from expected recovery. Track and document wound healing or other recovery milestones. Document the patient’s progress in comparison to previous findings.
• Ensure patients know when to follow up with you after leaving the hospital or surgical center. Provide clear, written instructions with specific dates or timeframes and information about post-operative follow-up appointments and criteria for seeking immediate medical attention. Consider including a link to the patient portal or a direct phone number for questions that arise between scheduled visits. Verify understanding by having patients verbalize the follow-up plan before discharge.
• Once patients are discharged from the hospital, coordinate care with their primary care physicians as needed. Send pertinent medical records — discharge instructions, medication lists, and postoperative care plans — to facilitate effective communication between all health care providers involved in the patient's recovery.

Documentation

Accurate, complete, and contemporaneous documentation can be your best defense against a malpractice claim or board action. Ideally, operative reports and dictation should be completed as soon as possible after a procedure.

Incomplete or late documentation can compromise patient care, as other physicians will not have access to important information needed for treatment decisions and continuity of care. This gap in communication could lead to duplicate testing, medication errors, or missed follow-up care.

When documentation is delayed, it may raise concerns about the accuracy and completeness of the medical record, potentially affecting both patient outcomes and the surgeon’s legal defense. It may also be argued that the physician could not have remembered the details of a procedure weeks or months later with the same precision and clarity as when the care was delivered. Documentation completed at or near the time of care provides the most accurate and defensible record of patient encounters and medical decision-making.

Documentation recommendations for surgeons include:

• If specialists are consulted during a patient’s surgical care, document any discussions and rationale for the course of treatment.
• Complete and sign off on operative notes promptly.
• If you use operative note templates, be sure that templates are updated appropriately to reflect the specifics of the procedure performed.
• If complications are encountered during a procedure, be sure they are thoroughly documented in the operative note.

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