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Wiki Operative Report Requirements

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marylee18

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Good Afternoon!

Our Hospital HIM department changed the format of our physician's Op Reports this week dropping the pre-operative diagnosis. I see on The Joint Commission's website that they state an immediate post operative progress note does not require a pre-operative diagnosis, but do not read that it changed their suggestion of including it in the Operative Report. Does anyone have any document/link/information if this no longer is suggested? Reference was dated 04/28/20 and referenced RC.02.01.03 EP 7

Thanks!
Mary Lee
 
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