Wiki Documentation on correct documentation placement of procedure notes in the EMR

[ashephard]

Does anyone know where to find documentation that we can print off to give to a physician for correctly documenting procedure placement in an EMR? I hope this is explained well enough. We have a physician that isn't wanting to place the procedures he does under procedures but he's documenting them under the A/P end of the chart under the diagnosis. We've asked him to document under the procedure area but continues not to. We don't want to be nit picky but are just wanting to make sure it's being documented correctly. Especially with ICD-10 coming and all the specificity of that we are trying to get everyone documenting the same way. So if it's not okay to document procedures in this area we are wanting to find some legit documentation to present to him so he realizes we aren't trying to pick on him. Thank you in advance for any help on this.

 

[cheermom68]

I don't think you are going to find anything official stating where it needs to be documented. As long as it is somewhere on the progress note it should be acceptable. Of course, best practice would be to have it in procedures, but if he is documenting it appropriately but just not where you want it, I would "pick my battles".