AHIMA Professional Practice Experience Workbook

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: Review the Subjective (S) section of the physician’s documentation. Describe the location and wound of the injury. Why would the physician order Keflex (a strong antibiotic) for this patient?

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