Question

Your doctor removed a piece of gravel from the patient's knee during the evaluation. Which additional documentation will you need?.

Answer 1

The additional documentation will you need is procedure note.

Procedure note

Procedure note is a note that entails important information about a patient medical history or the procedure of how the medication and treatment was given to the patient after being diagnosed.

Procedure note can contains the following

• The parts where the surgery was carried out.

• The name of physician or surgeon that performed the surgery.

• Pre and post operative diagnosis.

• Emergency  or non emergency procedure.

• Type of anesthesia given.

• Type of operation performed etc.

Inconclusion The additional documentation will you need is procedure note.

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