# documentation requirements for excision



## cllboyle (Apr 22, 2010)

My Chief of Surgery has developed a template for excision of a lesion, however there is a conflict as if there is enough documentaion to code.  Is further information required for the description of how the lesion was excised, see template below?  Please let me know if you feel this template is sufficient documentation or if additional documentation is needed.

Thanks!  

Surgery 
  General surgery
    Surgeon:
      (name): SMITH
    SURG PROCEDURE 1
      TIME OUT 
       OR/Procedure Area staff verbally confirmed through a time out: 
        Presence of the correct patient 
        Marking of the correct site (if applicable) 
        Procedure to be performed 
        Correct patient position 
        Availability of the correct implant/equipment (if applicable)
        Pre-OP Diagnosis:
          (narrative): skin lesion
        Post OP Diagnosis:
          (narrative): same
      Surgical procedure:excision skin lesion Lesion site:left upper arm
      Lesion Size:2cm X 1cm
      Excision size:4cm X 2cm
      Anesthesia:   1% Lidocaine w/o epinephrine
      Closure:  simple
      EBL:  minimal
    SURG PROCEDURE 2
        Pre-OP Diagnosis:
          (narrative): skin lesion
        Post OP Diagnosis:
          (narrative): same
      Surgical procedure: excision skin lesion
      Lesion site: left lower arm
      Lesion Size:1cm X 1cm
      Excision size:1.5cm X 2cm
      Anesthesia:   1% Lidocaine w/o epinephrine
      Closure:  simple
      EBL:  minimal 
    SURG PROCEDURE 3
        Pre-OP Diagnosis:
          (narrative): skin lesion
        Post OP Diagnosis:
          (narrative): same
      Surgical procedure: face
      Lesion site: right cheek
      Lesion Size:1cm X 2cm
      Excision size:1.5cm X 3cm
      Anesthesia:   1% Lidocaine w/epinephrine
      Closure:  layereddescribe)deep and superficial closed separately
      with running subcuticular
      EBL:  other: (describe)
        describe: 200 cc from the accessory artery of furman
  Patient tolerated the procedure: other: (describe)became agitated and
  started to having flashbacks from his death in 2003
  Patient discharged to: floor as noted above


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