Wiki Side of body in procedure note! Help!

[JJSearnock]

Good Morning All,

I was going over operative notes this morning and our one doctor has NO side that the procedure was on in any of his operative notes. I was always under the impression that the side had to be stated within the actual body of the note. Please let me know if anyone has any information on this! THANK YOU!!

 

[DRocole72]

It does. If it is not listed in the procedure performed than it has to be in the body of the Op report somewhere.

 

[KMCFADYEN]

And if it is not stated anywhere in the note get Doc to dictate addendum.