Wiki Anesthesia Diagnosis

[TLGray]

We have started using a new system and my AA and CRNAs are leaving off the diagnosis. Can I get my diagnosis from the op note or does it have to be on the Anesthesia record? Any help would be greatly appreciated. Thank you.

 

[LisaAlonso23]

You can obtain the dx from the op note, however the anesthesia record should be able to stand on its own to include the dx, procedure(s) and co-morbidity diagnoses.

 

[TLGray]

You can obtain the dx from the op note, however the anesthesia record should be able to stand on its own to include the dx, procedure(s) and co-morbidity diagnoses.

Thank you.