# Surgical Documentation Requirements



## tpgloc

I have been searching the internet for federal guidelines of requirements of documentation for surgical procedures. I have been looking for over 3 hours now and would like to know if anyone has ever found any kind of surgical documentation guidelines.  I have a physician that is asking me to produce the guidelines that state what is required in an operative report.  He feels that just the name of the procedure is fine and I should code what he tells me.  I am trying to tell him if it is not documented then it didn't happen and he wants me to show him where that is stated.  Can anyone help me?


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## bettyboopsandy

Why dont you ask the aapc maybe they can point you into the right direction.
Your doctor is crazy to think he doesnt have to note anything. I code outpatient surgeries. The way our physicians do is they record everything during the procedure and then hand that over to our dictation company and they they translate to paper and their is your operative report.


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## RebeccaWoodward*

I had this in my saved files....

http://www.jointcommission.org/Accr...o/Patient+Specific+Info/Operative_Reports.htm


(I do believe someone else from this forum provided this link in a previous post (??) )


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## mony94803

*Link doesn't work*

Hi

I am looking for the surgical documentation requirments and the link below doesn't work.  The website states the page is no longer found.  Can you please send the coding information?

Thanks
Simone


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## RebeccaWoodward*

I'm still looking for the guidelines.  I sent out a "SOS" on this forum a couple of days ago and haven't received any responses.  One colleague sent me this link...

http://www.jointcommission.org/NR/rdonlyres/F8046F2C-A8A2-412F-88D4-E1762BCC5C26/0/UP_Poster.pdf


As for my old link posted, I can't recall what that link contained.


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## KellyLR

*Surgical documentation requirements*

Well, I don't want to step on toes here but I typed in www.jointcommission.org  then typed "surgical documentation" into the "Search" tab and came up with 435 documents.  I briefly checked through to see if the search was successful and it was.  There are numerous types of requirement for surgical documentation according to specialty. I downloaded two myself!

Hope this helps!


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## RebeccaWoodward*

Been there, done that.  I am looking for something more *specific*...


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