Wiki Op note documentation

[richelle25]

Hello..

Just a quick question regarding documentation. Our PA is going to start assisting at surgery, just wondering how this should be documented on the op note..thanks

Sherry

 

[JMeggett]

Hello..

Just a quick question regarding documentation. Our PA is going to start assisting at surgery, just wondering how this should be documented on the op note..thanks

Sherry

There isn't any official "requirement" for documentation for a PA assist at surgery, that I've been able to find, but more & more insurance carriers are wanting documentation from the Surgeon of what the PA assisted him with before they'll reimburse for the PA. We now require our Surgeon's to add at the end of their operative note a breakdown of just what the PA assisted him with. A simple paragraph is sufficient.
Jenna, CPC

 

[richelle25]

thank you!!!

 

[penguins11]

Our docs usually list the PA as the assistant and then include a note at the end of the OR stating something like, "John Smith PA-C was present for the entire procedure assisting with suction, irrigation, instrumentation and closure."