Wiki Blanks in operative reports

abaer01

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One of my physicians is leaving some blanks in operative reports, probably from just not filling in the blanks in the templates. Example below:

"No further abscess or closed area was seen at this time. ____________ dorsally was lightly reapproximated and closed with 3-0 nylon plantarly. _____________, the wound was debrided and left open, debrided down through subcutaneous tissues down through bone, muscle tendon, excision debridement was performed plantarly and dry sterile dressing applied. The patient tolerated the procedure and anesthesia well. Vital signs stable."

Needless to say, this doc's operative reports don't read well in general, so I apologize for that. Regardless, can someone please point me in the right direction for documentation standards regarding blanks in operative reports? Or can someone please share some insight regarding this?
 
In my experience, blanks like this come from transcribed dictation in the event that the transcriptionist is unable to understand what the provider is saying in the recording. But you may also be correct that it is a template that has not been completely filled.

Your organization should guide you on how to handle this. But in any case, as with any documentation, if you are not able to accurate code from the report due to missing information, then it needs to be sent back to the provider for completion and/or clarification.
 
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