We have a provider who does many foreign body removals in the ear where this provider will only state " Right ear foreign body well packed on the TM today " and will state under procedure " Under microscope and speculum the right ear canal was visualized. There was a foreign body blocking view of the tympanic membrane. Using a suction the foreign body was taken off the tympanic membrane and removed. " .. But I noticed there is never documentation of what type of foreign body was removed from the ear (s). I don’t want to assume but I thought they should be documentation what type of foreign body was removed, not assumed " wax " in the ear, since impacted.
Can someone recommend or share a source where it specifies documentation guidelines for specifying type of foreign body removals, please???:confused: