Pre and PostOP Diagnoses:Suspicious symptomatic skin lesion left cheek and right lateral canthus.
Operative Findings: X has a 0.4 cm lesion on the left cheek and a 0.7 cm on the right cheek. Both have symptoms of irritation, inflammation, and growth in the recent past.
Procedure in Detail: After satisfactory anesthetic, each lesion was excised elliptically and submitted for histology. Wound closure ensued in a complex fashion with generous undermining and a multilayer closure each location. The patient was discharged. Follow up 10 days for sutures.
This is what I deal with daily. This is how all office lesion removals are documented. I don't feel that there is significant detail to justify complex closure. Am I being to harsh or can you help me locate black and white documentation that states that there needs to be more detail than this. My provider is stedfast that this is sufficient documentation.
Your help is greatly appreciated!
Thanks
Operative Findings: X has a 0.4 cm lesion on the left cheek and a 0.7 cm on the right cheek. Both have symptoms of irritation, inflammation, and growth in the recent past.
Procedure in Detail: After satisfactory anesthetic, each lesion was excised elliptically and submitted for histology. Wound closure ensued in a complex fashion with generous undermining and a multilayer closure each location. The patient was discharged. Follow up 10 days for sutures.
This is what I deal with daily. This is how all office lesion removals are documented. I don't feel that there is significant detail to justify complex closure. Am I being to harsh or can you help me locate black and white documentation that states that there needs to be more detail than this. My provider is stedfast that this is sufficient documentation.
Your help is greatly appreciated!
Thanks