injection documentation

All,

With EMR limits, how are people currently documenting injections? We have a procedure note within the visit, but someone in our office is inquiring if the procedure note can just state "the knee was injected...(with the normal medication information and procedure information) and the office visit would state which side was injected. I would rather err on the side of caution and have it be in the procedure note as I'm not sure an auditor would go hunting for which side was injected. Any thoughts?

Thanks,

Ashley

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