I am trying to provide documentation resources to my providers, showing them what needs to be included in operative/procedure reports. I have researched, but can only seem to find info on medical necessity, ordering of supplies, home health, etc. Does anyone have good articles on what needs to be in a note (medical necessity, risks of procedures, description of procedure, etc.) ? My providers sometimes seem to think that stating the did a certain procedure with no complications ( ex: SIS performed with no complications) is good enough to bill it! Thanks in advance!