documentation for minor procedures

adri3421

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Does anyone know how much documentation is required for minor procedures performed in an emergency setting (trauma bay)? For example what would be required for placement of a chest tube? Is "chest tube placed in trauma bay" enough?
 
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No, that's not enough

All procedure notes should have some basic information

Indications for procedure
Anesthesia / Analgesia given
What was done with some detail - approach, equipment used, findings - for this case I'd expect to see size of chest tube, where placed (Rt or left; which space)
Closure of surgical wound (if appropriate)
Any complications
Patient's condition at end of procedure

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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