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need clarification

  1. #1
    Default need clarification
    Medical Coding Books
    is an assessment/plan and reason for visit necesarry is the dr only performs a procedure?

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default Procedure Note
    Your procedure note should include:
    Patient identifiers (name, DOB, account #)
    Date of service
    Procedure Performed
    Preoperative Diagnosis
    Postoperative Diagnosis
    Type of Anesthesia/Analgesia
    Indications for Procedure (why you needed to perform)
    Findings
    Description of Procedure
    Blood loss
    Complications (if any, or state NONE)
    Condition of patient at end of procedure
    Physician signature

    Hope that helps

    F Tessa Bartels, CPC, CEMC

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