Wiki Procedure Note Documentation

[KoBee]

This is a in office procedure and sometimes i get confused on what is proper documentation for minor office procedure. I always thought there should be a detail note on how the procedure was done, kind of like step by step.

Is this proper documentation??


S: here for banding of one residual hemorrhoid complex
O: anoscopy reveals one complex
A: int hemorrhoidal complex
P: Banding
Procedure, benefits and risks discussed. All questions answered.


Banding times one performed without difficulty.

 

[nickelclaw]

For this yes code would be the same if done without or with anoscopy for banding 46221. as long as all key components are there and statement of procedure discussed benefits and risks...