MARIASOTO
New
Need feedback on the proper documentation of a procedure, I have included a snip of documentation we are seeing for some of our procedures in e.g. ( endometrial biopsy). Any feedback on if this qualifies as sufficient documentation would be greatly appreciated.
Pelvis: Ext nl
Vag nl, not a prominent cystocele, but not fully eval'd
Cx nl, descends well for LAVH, but borderline for straight TVH
utx af 10.5cm. lg amt tiss ???
No bladder assessment done
Pelvis: Ext nl
Vag nl, not a prominent cystocele, but not fully eval'd
Cx nl, descends well for LAVH, but borderline for straight TVH
utx af 10.5cm. lg amt tiss ???
No bladder assessment done