Surgeon: Was Anesthesiologist Present?
Y/ N (If no, state reason)
Informed Consent Signed Prior to Procedure? By Whom (patient or representative)? Discharge Instructions: Discharge Status: What facts (documentation) from the Objective (O) section of the physician’s note support the care that is being provided? What information provided in the Plan (P) supports the care that is being provided for one or more diagnoses for this patient encounter?
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