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Record of Care, Treatment, and Services (RC) Standards

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Element of Performance

When a full operative or other high-risk procedure report cannot be entered immediately into the patient’s medical record after the operation or procedure, a progress note is entered in the medical record before the patient is transferred to the next level of care.
This progress note includes the name(s) of the primary surgeon(s) and his or her assistant(s), procedure performed and a description of each procedure finding, estimated blood loss, specimens removed, and postoperative diagnosis.


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