My Chief of Surgery has developed a template for excision of a lesion, however there is a conflict as if there is enough documentaion to code. Is further information required for the description of how the lesion was excised, see template below? Please let me know if you feel this template is sufficient documentation or if additional documentation is needed.

Thanks!

Surgery
General surgery
Surgeon:
(name): SMITH
SURG PROCEDURE 1
TIME OUT
OR/Procedure Area staff verbally confirmed through a time out:
Presence of the correct patient
Marking of the correct site (if applicable)
Procedure to be performed
Correct patient position
Availability of the correct implant/equipment (if applicable)
Pre-OP Diagnosis:
(narrative): skin lesion
Post OP Diagnosis:
(narrative): same
Surgical procedure:excision skin lesion Lesion site:left upper arm
Lesion Size:2cm X 1cm
Excision size:4cm X 2cm
Anesthesia: 1% Lidocaine w/o epinephrine
Closure: simple
EBL: minimal
SURG PROCEDURE 2
Pre-OP Diagnosis:
(narrative): skin lesion
Post OP Diagnosis:
(narrative): same
Surgical procedure: excision skin lesion
Lesion site: left lower arm
Lesion Size:1cm X 1cm
Excision size:1.5cm X 2cm
Anesthesia: 1% Lidocaine w/o epinephrine
Closure: simple
EBL: minimal
SURG PROCEDURE 3
Pre-OP Diagnosis:
(narrative): skin lesion
Post OP Diagnosis:
(narrative): same
Surgical procedure: face
Lesion site: right cheek
Lesion Size:1cm X 2cm
Excision size:1.5cm X 3cm
Anesthesia: 1% Lidocaine w/epinephrine
Closure: layereddescribe)deep and superficial closed separately
with running subcuticular
EBL: other: (describe)
describe: 200 cc from the accessory artery of furman
Patient tolerated the procedure: other: (describe)became agitated and
started to having flashbacks from his death in 2003
Patient discharged to: floor as noted above