Crucial Documentation Components of the Operative Note

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  • June 15, 2015
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Crucial Documentation Components of the Operative Note

by John Verhovshek, MA, CPC
A surgeon’s operative notes should stand alone to provide all the necessary documentation to describe the procedure(s) performed. Every operative note should include:

  • Patient’s name
  • Date
  • Preoperative Diagnosis
  • Postoperative Diagnosis
  • Surgeon’s Name
  • Assistant Surgeon/Co‐Surgeon
  • Procedure
  • Indications for Surgery
  • Findings at Surgery
  • Details

When possible, differentiate pre-operative and post-operative diagnoses. For instance, a pathology report may provide additional details that allow for a more specific post-operative diagnosis. You may also report underlying, co-morbid conditions that can affect the surgical outcome (some ICD-9-CM manuals designate co-morbid condition codes using a dedicated symbol).

John Verhovshek
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About Has 601 Posts

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

No Responses to “Crucial Documentation Components of the Operative Note”

  1. Bhavani Babu says:

    Hello,
    In performing a major heart surgery, it is required that an assistant surgeon be present for the entire surgery in a non-teaching hospital. Is it necessary to mention specifically what the assistant surgeon did? We have been using Modifier 80 (or AS when it is a qualifed PA).
    Thank you.

  2. Kelly says:

    Good question Bhavani! Did you ever get a response?

  3. Christine Erdman says:

    What are considered “Details”?

  4. Christine Erdman says:

    What are included in the “details”?