I need a second opinion on the documentation requirements for moderate sedation. I feel that the operative note must state that the physician: 1) administered or supervised the administration of moderate sedation, 2) the meds used, 3) an independent observer monitored the patient, and 4) the intraservice time. The physician is saying that he does not need to document any of this. He is saying that all he must document is the meds used and that everything else is in the nurse's note. He's refusing to add any of the other information into the note and demanding that I re-bill for moderate sedation. That just doesn't seem right to me. I've been taught that if it's not in the operative note then it didn't happen. Am I wrong or being too stringent?