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Wiki Sufficient documentation

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MARIASOTO

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Need feedback on the proper documentation of a procedure, I have included a snip of documentation we are seeing for some of our procedures in e.g. ( endometrial biopsy). Any feedback on if this qualifies as sufficient documentation would be greatly appreciated.

Pelvis: Ext nl
Vag nl, not a prominent cystocele, but not fully eval'd
Cx nl, descends well for LAVH, but borderline for straight TVH
utx af 10.5cm. lg amt tiss ???
No bladder assessment done
 
Insufficient documentation

Hello,

The snip-it of the documentation for your procedures is insufficient documentation; it looks more like an examination performed during an e/m service. Is your provider using an EMR system? I would recommend seeing if some type of template could be set up for their procedures, this way they will be geared to document correctly.




M. Hannus CPC, CPMA, CRC
 
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