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Educational Schedule - March 2014 (PDF)

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Make Sure Reports Reflect True APLs

By Harry C. Sax, MD, MHCM
Professor and Executive Vice Chair, Department of Surgery
Physician Liaison, Cedars-Sinai Medicine Clinical Transformation Initiative

We are required to report episodes of accidental puncture or laceration (APL) that occur during procedures. The spirit of the regulation is to capture true deviations, such as blindly inserting a laparoscopic trocar into the aorta.

But the determination of what is a true APL is open to interpretation. In addition, APL is part of an individual physician's performance metrics and is currently publicly reported by the institution.

For many years, Cedars-Sinai performed poorly in this realm, due to our tendency not to document the extensive nature or severity of the disease process. For example, a loop of ileum, completely adherent to the uterus from endometriosis, would be entered while attempting to free it. The gynecologists would dictate that the bowel was inadvertently entered, and we would report this as an APL.

With education of our Ob-Gyn colleagues to document that this was unavoidable and intentional as part of the procedure, the rate has dropped dramatically and more clearly reflects true APLs. As surgeons, we can be more accurate in our dictations. If there are extensive severe adhesions, document that. Think about these two statements, both regarding the same operation:

  • "The colonic disease process involved the ureter, which required segmental resection and primary anastomosis over a double J stent."
  • "In mobilizing the diseased colon, the ureter also was divided, which we fixed."

The second would be coded as an APL, the first would not.

As you dictate your operative reports, think about how to make it clear to the reader (and coder) what you were dealing with. And our reporting will more accurately reflect the high quality of our care.