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Wiki what is require on a op report

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kstark

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the surgeons sometimes leave off "operation performed","post operative diagnosis" but put the information in the body of the report. Can we still code or do we ask the surgeon to amend.

thanks,
 
The information IS there

If I understand you correctly, kstark, the information is present, but just not under the correct section (subtitle).

If the information is present ... regardless of where it is in the report ... I do NOT ask the surgeon to amend.

If the information is missing, I ask the surgeon to amend.

F Tessa Bartels, CPC, CEMC
 
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