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Proper Documentation

  1. #1
    Default Proper Documentation
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    Would this be acceptable documentation for a laceration repair or does it need to be more in depth?

    Laceration Repair
    Date/Time: 11/8/2018 1:12AM

    Performed by: Dr. X

    Authorized by: Dr. X

    Consent: Verbal consent obtained.
    Body area: head/neck

    Location details: scalp
    Laceration length: 3 cm
    Irrigation solution: saline
    Amount of cleaning: extensive
    Skin closure: staples
    Number of sutures: 5
    Dressing: antibiotic ointment

  2. #2
    Default Poor Documentation
    I disagree with that form of provider documentation...looks like a checkoff. He or she provider needs to tell what is wrong with patient and M.E.A.T with conclusions. If management cannot get him or her to change well ......

    Good Luck
    Lady T

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