Wiki Operative report documentation

[AmandaW]

I learned through a Medicare - Novitas representitive that they go by JCAHO standards for Op note documentation and I've gone to that site. I'm still having trouble finding exactly what is REQUIRED in the operative report.
And can we code/bill from the information on the 'brief note'?
Thank you for any information you have!

 

[Chelle-Lynn]

The following are the required elements for JCAHO for Op Documentation:

Name of physician/surgeon and assistant surgeons
Findings
Procedure Performed
Description of Procedure
Estimated Blood Loss
Specimens Removed
Post Op Diagnosis
Documentation by physician that potential benefits, risks, or sideeffects, including potential problems related to recuperationwere discussed.The completed operative report is authenticated by the surgeon and made available in the medical record as soon as possible after the procedure



See: [FONT=TimesNewRoman,Bold]JCAHO Standard IM.6.30
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[AmandaW]

THANK you a ton!!!