Posted on 14. Aug, 2009 by in Toolkit
Unless you want to grapple with denials, the procedure notes that support your physicians’ laceration repair claims should contain these 8 elements. How do the physicians in your practice measure up?
• decontamination (including foreign material removed)
• tissue management
• exploration of wound and contiguous structures
• anesthesia technique
• repair of underlying structures.
Example: A good procedure note for a simple scalp repair might read: “After cleansing with betadine, repaired single-layer scalp wound, 8.4 cm, with 14 4-0 prolene sutures under local anesthesia. No foreign material removed; no repair of underlying structures or tissue management required. Wound and surrounding structures...
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