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what is require on a op report

  1. Default what is require on a op report
    Exam Training Packages
    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.


  2. #2
    Seattle First Hill
    We always ask our surgeons to amend them.

  3. #3
    Milwaukee WI
    Default 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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