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Wiki ED documentation help

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dette13

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If the doctor does not fill in the length of repair for a laceration, but the triage nurse documents "approximately" 2 inch laceration, is it appropriate to charge/code for this laceration without the documention from the MD if he has checked of the "reviewed nurse's notes" box? Or would you HAVE to send back for the MD to document? Or just SHOULD you? Or not at all?

thanks
 
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