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Thread: documentation of surgeries

  1. #1

    Default documentation of surgeries

    AAPC: Back to School
    I have a doctor in my facility that is questioning if this is legal. Does an operative report have to be a written document in the patients chart OR can the op note be an audio on a cd and kept inside the chart? Does anyone know where I might look to find something documented on this so that we may show him if this is or is not acceptable? Any help would be greatly appreciated.

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default How would he transmit to other providers?

    If it's only on an audio CD how would he share this info with other providers, insurance company, even the patient him/herself? Also how can the surgeon "sign" his work if it's audio. Who is to say whether that is the surgeon dictating?

    Also most facilities require an operative report in the chart within 24-48 hours.

    I'd check with CMS for more guidance. It just makes sense that the document should be in a written format (typed or handwritten).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Join Date
    Apr 2007
    North Carolina


    Both residents and teaching physicians may document physician services in the patient’s medical record. The documentation must be dated and contain a legible signature or identity and may be: ■ Dictated and transcribed; ■ Typed; ■ Hand-written; or ■ Computer-generated.

    I'm still looking for any other CMS citations

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