Wiki Hospital Procedure documentation

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yrmcpc

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I am sure I already know the answer but am wanting confirmation.

I have a new doc I am coding for. He basically only documents the findings and references the "event log" if you want details of the procedure. Is this acceptable documentation? It is alot harder for me to code and confusing. I am trying to get him to document the whole procedure in the procedure note, but he states that is duplicating his work and feels it is unnecessary. I don't want to create more work for him if it is really unnecessary.

Any suggestions? Thanks!
 
yrmcpc said:
I am sure I already know the answer but am wanting confirmation.

I have a new doc I am coding for. He basically only documents the findings and references the "event log" if you want details of the procedure. Is this acceptable documentation? It is alot harder for me to code and confusing. I am trying to get him to document the whole procedure in the procedure note, but he states that is duplicating his work and feels it is unnecessary. I don't want to create more work for him if it is really unnecessary.

Any suggestions? Thanks!
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What kind of procedures does he do?


The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standard IM.7.3.2 requires that you consistently place operative reports in the medical record according to your hospital policies and procedures and state laws. This requirement applies to outpatients as well as inpatients.

Most hospitals create policy and procedure by first referring to state law to determine if there are any specific requirements, and then referring to medical record and surgery text books for additional guidance. Classically, the record should include as applicable to the case:

Patient's name and unit number

Date of procedure

Name of surgeon and assistants

Pre-operative and post-operative diagnoses

Anesthetic agent used

Description of the findings, techniques, and procedure

Specimens removed

Any laboratory or diagnostic procedure ordered

Condition of patient
 
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