Outpatient Surgery Magazine - Subscribers

What's the Harm? - December 2015 - Outpatient Surgery Magazine

Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.

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1 4 8 O U T P AT I E N T S U R G E R Y M A G A Z I N E O N L I N E | D E C E M B E R 2 0 1 5 have become incredibly onerous. This week I finished seeing patients at 4:30 p.m. Monday and concluded dictating at 3 p.m. Tuesday. When my coding is complete, there are more entries than the captain's log book on Noah's Ark. Let's look at the documentation necessary for fracture care (the mnemonic LEO C FAR applies): L Location and laterality. I hope we get this right. E Encounter (initial or subsequent). Tell the truth, Doc! Initial pays more. O Open or closed? Duh! C Classification. Choose your weapon. C Category of fracture (growth plate, pathologic, stress). Aren't all fractures stressful? C Cause (medications, age, trauma). Do in-laws apply? F Fracture pattern (transverse, spiral, comminuted). How about "weird?" A Alignment (displaced, non-displaced). Does "pretty good" work? R Result (routine healing, delayed healing, non-union, etc.). Make sure no lawyer is within a 5-mile radius. Indications for surgery Operative notes are no picnic either. ICD-10 requires "indications for surgery" in the formal operative report. Surgeons have to document why the patient was brought to the OR. Catchphrases such as "6 months of failure of conservative therapy" may suffice. Other termi- nology such as "I thought he needed it" or "I was behind on my car payments" won't fly. Exact findings at surgery must be well-annotated. Expressions such as "The rotator cuff was jacked up" will result in insurance denial — C U T T I N G R E M A R K S

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