I have been searching the internet for federal guidelines of requirements of documentation for surgical procedures. I have been looking for over 3 hours now and would like to know if anyone has ever found any kind of surgical documentation guidelines. I have a physician that is asking me to produce the guidelines that state what is required in an operative report. He feels that just the name of the procedure is fine and I should code what he tells me. I am trying to tell him if it is not documented then it didn't happen and he wants me to show him where that is stated. Can anyone help me?