• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki documentation for minor procedures

Create Wiki
A

adri3421

Networker
Messages
38
Location
Heiskell, TN
Best answers
0
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?
 
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
 
You must log in or register to reply here.
Top