# documentation requirements for major/minor joint injections



## jenldavid34 (Apr 17, 2020)

I have a provider that documents the following:

RIGHT ACROMIOCLAVICULAR JOINT INJECTION:  After informed verbal consent was obtained from the patient, the patient's appropriate shoulder was identified and prepped. A 25-gauge needle was used to enter the joint, and 2 mL of corticosteroid with 0.25 mL of 1% lidocaine (10 mg/mL) was injected sterilely into the AC joint, and a Band-Aid was placed. The patient tolerated the procedure well.

For the most part, the procedure note looks good except for the drug injected. Now he has selected in the system of what steroid was injected but his dictation of the procedure note doesn't reflect what was selected. In regards to auditing, does the drug injected need to be documented within the body of the procedure note?


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## SharonCollachi (Apr 17, 2020)

It has to be in the procedure note.  The billing system (what it looks like you are referring to) is not part of the documentation.


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