Question Procedure documentation question

debellis59

Networker
Messages
33
Location
Kennewick, WA
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Hi! I have a new provider who insists that she doesn't need to document her procedure inside the note. For example, she gave a patient (new to her) a hip injection, made a note separately for the injection, and states in the body of the E&M note "We elected to try another intra-articular steroid injection. For details please see the procedure note." I asked her to please enter the note into the body of the chart note and her response was "I am not sure why it needs to be in the note. It is my understanding that as long as it is referenced in the note the actual documentation does not need to be there. Is that a new coding thing?"

I've not been able to find anything that specifically states that it must be in the body of the note, but I know that's been our practice. Does anyone have a link that shows this? Or is this an acceptable practice?
 

trarut

Guru
Messages
249
Location
Columbus, OH
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I agree with your provider on this. It doesn't matter if the procedure is documented in the visit note or a separate procedure note, just that it is documented appropriately. Does your organization have a policy that mandates they be documented together or is it just how it was always done so it has become the norm?
 
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