What is required in medical record documentation when additional work is performed during a procedure?

When additional work is performed during a procedure, the medical record documentation must include support for the substantial additional work that has been done. This requirement ensures that the extra time, effort, and resources expended during the procedure are adequately justified in the documentation. Properly documenting this additional work is crucial not only for clinical accuracy but also for appropriate billing and coding purposes, as reimbursement may depend on the demonstration of the extra services provided.

While obtaining evidence of the patient's consent, verifying insurance coverage, and adhering to standard procedure protocols are important aspects of medical practice, they do not specifically address the need to document the additional work undertaken during a procedure. Thus, focusing on providing support for substantial additional work is essential for proper medical recordkeeping and compliance with coding guidelines.