# Documentation Requirements for in-office procedures



## saddie2k (Jul 30, 2018)

Hello,

Trying to find out if an op note/procedure note is REQUIRED for any/all procedures performed in office?

I need to know if it is written somewhere in black and white that a procedure note with details including pre-op prep and post-op/discharge instructions is needed even when performed in an office setting. OR if it is NOT and just a note in the impression stating what was done is sufficient. 

very basic examples:
1) Conjunctival Foreign Body - removed @ slit lamp today
2) DES - Occluded OU lower lids size/brand/lot#
3) Increased IOP 42. IOP 19 after tap.

Also, are consents REQUIRED for the office procedures? Or is a notation in the impression that the info was discussed with the patient and they agree to proceed ok? 

If the answer is YES to the above questions, is there anywhere that it states this in black and white? This is a reoccurring discussion and I have been searching with no concrete assurance one way or the other. 

Jenn Serakowski, OCS


----------



## bmjohnson73 (Oct 9, 2020)

I am in need of an answer for the same issue.  Did you ever receive guidance?


----------



## saddie2k (Oct 9, 2020)

No, I never got any responses.


----------



## SharonCollachi (Oct 9, 2020)

Perhaps your malpractice carrier has something, because you will definitely lose in any malpractice situation.  I would contact them (yes, I'm serious).


----------

