Wiki Joint injections

[mwarmke]

I'm looking for any articles out there on what should be in a physicians documentation for joint injections

 

[mbort]

I dont know of any articles, but my personal thoughts on the matter are that these should be treated as procedures (cuz thats what they are)

the specific body part was prepped and drapped in a sterile fashion. A ______ g needle was used with whatever medication was injected and specifically where it was injected and why it was injected as well as potential outcome. The patient tolerated the procedure well/or not well...follow up will be prn or in _____ weeks.

In addition to the above, it would not hurt for the doc to dictate or document risks, expectations from injection, precautions, etc.

EDIT:
Also if this is NOT a planned injection, then the doc needs to make sure that his documentation for the E/M visit also supports the use of modifier 25 so that he can capture that as well.

 

[mwarmke]

thanks Mary