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need clarification

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

  2. #2
    Milwaukee WI
    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)
    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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