Wiki Op Report - Pre-Procedural Patient consent

[KoBee]

Unable to locate documentation guidelines in regard to good practice on op reports, if anyone can direct me to a source, I would appreciate it.

We have a provider who does pain injections, usually majority of our providers put a patient consent on the op report, but this provider does not. Is it a requirement that it must be documented in the body of the op report?



Here is one example from a provider:
Procedure in detail: Informed consent obtained after explaining the procedure and potential complications including local discomfort, infection, headache, temporary or permanent weakness and/or numbness of one or both legs, temporary or permanent paraplegia, heart attack and stroke.

 

[thomas7331]

Typically for minor procedures with low risk, a physician may document the patient's verbal consent in the body of the note, but for more extensive procedures that involve greater risk there will be a separate consent form that the patient signs in advance.

But because patient consent requirements are a serious legal and medical-ethical issue and one that requires knowledge of state laws, this is not really within the scope of coding, and I would recommend you refer a question like this to your practice's attorney and not rely on advice from a coding forum. Your organization should really have a policy in place to direct you on how and when physicians will obtain and document consent and not require you as a coder to independently determine the answer to this.