# Operative Report Audit



## t.rock.tara (Sep 29, 2009)

Is there a specific auditing form for procedures/op reports? I have a very helpful E/M audit form but nothing for op reports. Any help is appreciated!!


----------



## fredabrinson (Oct 17, 2009)

*Procedure note auditing form*

I've never seen anything like this, but it's possible to develope your own auditing tools.  I did this for E&M auditing, but I have also done this for other auditing projects.  I find that I work better when I read the regulations on the subject I am auditing, and develope my audit tool from those CMS regulations.

In your question of auditing procedure notes, it could be difficult to create individual procedure audit sheets, but if you are auditing some of the same procedures, it may be worth it to take the time to do so.

You could also develope a "master" audit tool for all procedures (things that would be required no matter what the procedure), such as patient name, pre and post op diagnosis, physician name, procedure name, date, justification for the procedure, complications, outcome, physician signature, etc.  Your employer may also have certain requirements that must be met, such as physician signature within a certain time frame.

There are also some requirements in the Codes of Participation. These are usually included in your hospital policies, but it is always a good idea to verify this.

Good luck!


----------



## t.rock.tara (Oct 19, 2009)

*Op Report Audit*

Thanks so much for your help!!


----------

