Procedure description documentation

rmooney1114

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Monson, MA
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I have a provider who when doing a procedure will only document the procedure and the findings as a result of that procedure, but does not document or describe what was done during the procedure. Example is when doing an a 46600 (Anoscopy) the provider only documents for the procedure; Anoscopy, result hemrroids. In my opinion the provider should be documenting consent, complications if any, how the patient tolerated the procedure, and a description even if brief of what was done during the procedure.. Provider is stating no, they have only ever documented what procedure they were doing to be performing and the result and that is it... Thoughts on this? Does anyone have any resources to support?
Thank you
 
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