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Post Operative Pain Block dictation

L Loring

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Can someone please tell me if nerve blocks for post operative pain need to have dictaion for the block or can they use a coding sheet where the information is recorded?

If dictation is required for the blocks where would I find that information (resource) to show the Dr.?
 

jdrueppel

Expert
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435
Location
Lincoln, NE
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No, a "dictation" of the service is not required. It must, however, be documented in the patient's medical record. My physicians document these services in the Progress Notes or on the anesthesia record. We have a separate "procedure page" to the anesthesia record and they hand write their procedure documentation.

Julie, CPC
 

L Loring

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thank you so much for the information. can you please tell me where that is documented that dictation is not needed.

Thank you so much,

Linda
 

jdrueppel

Expert
Messages
435
Location
Lincoln, NE
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0
No, but I have never seen anything stating it has to be dictated either. In addition, I have never had a problem with any payers (governmental or private) not accepting copies of our hand written documents.

Julie, CPC
 
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