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.
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.