cmacpc
Networker
Not sure on the guidelines for this. So any help is appreciated because the group I code for does this from time to time. Here is the case I have in front of me now:
Anesthesia start time: 11:26
Surgery start time: 11:43
Surgery end time: 12:44
Anesthesia end time: 12:50
The problem is that on the anesthesia record where the vitals are recorded (timeline) the documentation of the vitals stops @ 12:37. In the comments section the last entry is "surgery started 11:43" nothing after that. My question is regarding documentation on the timeline, is it as criticle part of the record as everything else. My guess is yes, and without this documented what time would you be able to bill up to? is the record is incomplete? Any insight would be appreciated.
TIA
Anesthesia start time: 11:26
Surgery start time: 11:43
Surgery end time: 12:44
Anesthesia end time: 12:50
The problem is that on the anesthesia record where the vitals are recorded (timeline) the documentation of the vitals stops @ 12:37. In the comments section the last entry is "surgery started 11:43" nothing after that. My question is regarding documentation on the timeline, is it as criticle part of the record as everything else. My guess is yes, and without this documented what time would you be able to bill up to? is the record is incomplete? Any insight would be appreciated.
TIA