Clinical Documentation Tip Sheets

Surgical Specialties

This tip sheet is designed to assist physicians in accurately assessing and documenting the severity of illness in hospitalized patients within the electronic medical record (EMR).

DEBRIDEMENT

> Type: excisional or non-excisional

> Deepest level of debridement: skin, subcutaneous tissue, muscle, bone

> Tissue removed: necrotic, devitalized, viable, or non-viable

> Avoid: I&D spell it out; incision and drainage, or incision and debridement

LYSIS OF ADHESIONS

> Document significant lysis of adhesions adding to surgical complexity or difficulty. Include duration of added OR time.

> Include details (e.g., complete, significant, extensive, etc.

> Specify anatomy being released or freed (e.g., duodenum, jejunum, right/left atrium, liver, other)

> Example: “…there were significant adhesions to the anterior abdominal wall… we lysed the adhesions…this took approximately 60 minutes to complete and increased the difficulty of the case. ”

IMAGING REPORTS AND PATHOLOGY REPORTS

> Remember to add to your notes the imaging reports and pathology reports and indicate the clinical significance of the findings .

OPERATIVE REPORT DOCUMENTATION (INCLUDE ALL OF THE FOLLOWING):

> Preoperative diagnosis: diagnosis and associated symptoms

> Postoperative diagnosis: if different from preoperative diagnosis

> Indication for surgery: medical necessity (see MN Tip Card)

> Operation performed: name of the procedure with location details (indicate if different from scheduled procedure might need a new authorization or change surgery status from outpatient to inpatient)

> Technique/Procedure details

> Findings section: Document incidental findings during the procedures (might add to severity of illness). Document insignificant, routinely expected or integral occurrences here.

> Complications section: Avoid documenting insignificant, routinely expected or integral occurrences here