Documentation Suggestions

Expected Documentation

  • Quantity: "Each; each separate/each additional; single; multiple; any number"
  • Severity: "simple; complicated; extensive"
  • Inclusive: "With; without"
  • Classifications: "Simple; Intermediate; Complex"
  • Measurements: "xx cm in length"

Services Assumed

  • Prep and Drape
  • IV access
  • Dissection and identification of anatomy
  • Incision and Closure
  • Simple debridement or irrigation
  • Lysis of simple adhesions
  • Surgical cultures
  • Wound irrigation
  • Drains
  • Preoperative, intra-operative and postoperative documentation - including photographs, drawings, dictations and transcriptions as necessary. 

The Latest Trend

Demand for more "grammatical clarification." (Must document not only actions, but intent. "What were you thinking?") The physician operative note is the source document. That is, if it was not documented, it was not performed. The operative note should paint a picture of the patient's encounter. It is ok to say the case was difficult. Document the necessity of each procedure preformed.

For Example:

PREOPERATIVE DIAGNOSIS: Periampullary neoplasm

POSTOPERATIVE DIAGNOSIS: Periampullary neoplasm

TITLE OF OPERATION:

    1. R0 pylorus preserving pancreatoduodenectomy.
    2. Regional lymphadenectomy.
    3. Placement of jejunostomy feeding tube.

ASSISTANT:

ANESTHESIA:

ANESTHESIOLOGIST:

ESTIMATED BLOOD LOSS:

COMPLICATIONS:

FINDINGS:

    1. Placement of jejunostomy feeding tube distal to anastomoses for nutritional support during postoperative period.
    2. Adhesions from prior surgery contributed significantly to the difficulty of this case.

INDICATIONS FOR SURGERY: This patient has known periampullary neoplasm …

*Extracted from a presentation organized by the SSO Coding & Reimbursements Committee at a recent SSO Annual Cancer Symposium.