Health Information Technologies and Processes

Procedure Note for 2nd Degree or Higher OB Laceration Repair

  • 1.  Procedure Note for 2nd Degree or Higher OB Laceration Repair

    Posted 28 days ago
    Do you ask providers to document a procedure note for the suture of a 2nd degree repair on a delivery.  Or would you accept delivery summary stating:
    " 2nd degree perineal and vaginal tear with sulcus extension both repaired"  as a procedure note to code from?

    Thanks for the input.

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    Stacey Goodenough
    Manager of Medical Records / Privacy Officer
    Wayne Memorial Hospital
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