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Wiki Anesthesia Diagnosis

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TLGray

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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.
 
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.
 
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