Wiki Procedure Titles

[mmwarren]

When a procedure is being done in the office does the procedure note need a title? Example: Nasal Endoscopy. We are having conflicting issues with this, stating the procedure note done does not need a title for a procedure. I believe if you do a procedure you should have some kind of title stating what the procedure is.
Thank you!!

 

[ardithch]

Usually when the provider dictates the procedure, he/she will title it "procedure note" as opposed to "consultation note" or "progress note", for example. What's important is that the body of the note includes the pre-operative and post-operative procedure, diagnosis, and procedure performed, details, etc.

Hope this helps,

Ardith, CGSC