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Things to Consider While Preparing Procedure Notes The aim of the procedure note or clinical note is to document why and how a medical procedure was done, when it was performed and the patient's response to the procedure. Procedure notes typically detail a procedure performed in a physician’s office, at a hospital bedside, or in a specialty clinic. These notes can be used for a wide variety of procedures such as a biopsy done at a dermatology clinic, orotracheal intubation done in the emergency room (ER), or the removal of sebaceous cysts in a family practice. Let’s see what should be included in the reports when transcribing them. Components of a Procedure Note In some cases, clinical notes simply name the procedure and give a brief summary along with the pertinent findings. In other situations, clinical notes are precisely formatted and have procedure-specific subheadings. In both cases, the first thing is to identify the procedure performed, as follows: PROCEDURE PERFORMED - Triple lumen catheter (TLC) placement The other components of these notes are as follows:
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Indications – The body of procedure note starts with the explanation of why the procedure mentioned is being performed. INDICATIONS FOR PROCEDURE
- This is a 70 year old male who needs IV access. Alternative names of this section are: ‘Preoperative Diagnosis’ and ‘Reason for Procedure or History’ (when more detail is included). •
Medications – A list of patient’s current medication is included and needs to be numbered and listed vertically in the transcript of the procedure note (an example shown below). Suppose a colonoscopy is performed on a patient and the current medications are Ambien and Plavix, which should be transcribed as follows: CURRENT MEDICATIONS 1. Ambien. 2. Plavix.
There is no need to number vertically listed anesthesia or procedure-related medications unless specified by the healthcare facility. Such medications may be transcribed as:
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PREMEDICATIONS Versed 5 mg, Demerol 75 mg IV. •
Description of Procedure – This section provides a narrative description of the procedure under the titles such as PROCEDURE IN DETAIL, PROCEDURE SUMMARY or TECHNIQUE. If a particular procedure includes measurements as part of the process, these are also linked to the narrative.
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Findings and Recommendations – If postoperative diagnoses is not stated at the beginning of the report or bundled into the procedure description, the results of the diagnostic study should be listed vertically with number under the section titled Findings, Conclusion, or Impression along with Recommendations (listed horizontally separated by comma), if any.
Importance of Accurate Procedure Notes • Procedure notes provide the complete picture of how a patient is doing medically, which helps the physician understand the patient’s case, so that the condition can be diagnosed and treated. Error-free procedure notes are necessary to identify complications and provide appropriate treatment. •
Accurate procedural documentation is essential for medical coders to assign appropriate CPT codes so
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that the physicians can receive proper and timely reimbursement for services rendered. • If they are curious about something, patients do have the right to look at their medical chart and consult their physician about the same. They can also petition to correct inaccuracies in their charts. Accurate procedure notes clearly and concisely record relevant data about medical procedures and can protect medical practices from legal consequences. In most cases, physicians find it difficult to document procedure notes and focus on their core task of patient care at the same time. That’s why most rely on experienced medical transcriptionists for the transcription of their clinical notes in correct format and send back to the physicians.