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Wiki Proper Documentation

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LissaBridget

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Lake In The Hills, IL
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Would this be acceptable documentation for a laceration repair or does it need to be more in depth?

Laceration Repair
Date/Time: 11/8/2018 1:12AM

Performed by: Dr. X

Authorized by: Dr. X

Consent: Verbal consent obtained.
Body area: head/neck

Location details: scalp
Laceration length: 3 cm
Irrigation solution: saline
Amount of cleaning: extensive
Skin closure: staples
Number of sutures: 5
Dressing: antibiotic ointment
 
Poor Documentation

Hi
I disagree with that form of provider documentation...looks like a checkoff. He or she provider needs to tell what is wrong with patient and M.E.A.T with conclusions. If management cannot get him or her to change well ......

Good Luck
Lady T
 
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