Wiki Cancelled procedure documentation

arkassabaum

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There seems to be some debate. In an outpatient/day surgery setting, does a provider need to document the reason why a procedure was cancelled and sign off on it? Or is it sufficient for the nurse to write the reason why in a progress note/nurse note. Specifically if its cancelled due to pt request, the case in question showed no medical reason as to why and the pt was not seen by the provider. Looking for specific guideline or rule, having difficulty finding clear answer. Thank you
 
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