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Procedure Note

Your procedure note should include:
Patient identifiers (name, DOB, account #)
Date of service
Procedure Performed
Preoperative Diagnosis
Postoperative Diagnosis
Type of Anesthesia/Analgesia
Indications for Procedure (why you needed to perform)
Findings
Description of Procedure
Blood loss
Complications (if any, or state NONE)
Condition of patient at end of procedure
Physician signature

Hope that helps

F Tessa Bartels, CPC, CEMC
 
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