Query v/s Addendums to OP Reports

lucy.walton@eamc.orglucy.walton@eamc.org
in Physician Advisors

Good morning, I have a question regarding queries v/s addendums to Operative reports. Once the OP report has been verified/signed by the Physician can a query be used to ascertain missing elements like Pathology specimen removed, site cauterized to control bleeding, vessel cut or ligated, site of endarterectomy,  or is it a CMS or joint Commission requirement that addendums be done to add this information to OP reports?

Comments

  • lprescott1lprescott1
    at my facility an addendum would be applied to the op report. I suggest you speak to your HIM director who should be able to give you guidance.
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