arkassabaum
Contributor
I have an ortho provider who is refusing to document his procedure further than "today we injected the knee with 40mg kenalog" I am trying to explain to him that any and all procedures should include at minimum: 1) Indications for procedure (medical necessity) 2) Anesthesia/Medication given (include dosage) 3) What was done with some detail – site, approach, equipment used, findings 4) Closure of wound (if appropriate) 5) Any complications 6) Patient's condition at end of procedure. He wants something from the aaos or cms stating this is required and for the life of me I cannot locate guidelines that clearly support any or all of these item. Our templates in the system are built to include this info but he is not using them.