Surgical Documentation Guidelines - group of Oncologists

crhunt78

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I am trying to teach a group of Oncologists how to document op reports when they do bone marrow biopsies. Does anyone know where I can find any guidelines on how to document an op report? I come from a general surgery background but most surgeons know how to document what they did; oncologists/hematologists are harder to teach. ;)Thanks!
 

aprram77

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Typically the oncologist will do a Procedure note for the bone marrow bx and not a Op note. Below is example of what is needed for these procedure documentation.

PROCEDURE:
Bone marrow aspirate and biopsy.

INDICATION:
Pancytopenia.

PROCEDURE OPERATOR:

CONSENT:
Consent was obtained from the patient. The risks and benefits were explained. The patient agreed to undergo the procedure. The consent form was signed and placed in the chart.

PROCEDURE SUMMARY:
The patient was laid in the <LEFT/RIGHT> lateral decubitus position. The <LEFT/RIGHT> posterior superior iliac spine was prepped and draped in a sterile fashion. The patient was premedicated with 10 mg of morphine sulfate IV and 1 mg of Ativan IV. The crest of the posterior superior iliac spine was located, and the skin as well as the surface of the bone was anesthetized with 1% lidocaine. A Kelly needle was introduced, and bone marrow aspirate was obtained without any difficulty. This was withdrawn, and the Jamshidi needle was advanced into the bone cavity. A bone marrow biopsy was obtained without any complications. Dr. ___ was present for the critical part of the procedure.
 

crhunt78

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I know what needs to be included, I was just wondering if there are any guidelines or documentation from a trusted source (CMS, Medicare, etc.) about how to document a procdure note. A bone marrow bx is a surgical procedure because it is invasive. No, it is not as extensive as a mastectomy or appendectomy but it needs to be documented the same way. The doctors I work for are trying to use a template that has little to no information in it and I need guidelines to show them what Medicare or an insurance carrier wants to see if they were to request documentation.
 
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