Operative Note Documentation Basics

Operative Note Documentation Basics

A surgeon’s operative note should provide all the necessary documentation to describe the procedure performed. The note should “stand alone” as the only document needed to understand why the surgery was undertaken, and what occurred.
The following documentation that should be on every operative note:

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

Include Post-Op Diagnosis in Operative Note

Whenever possible, try to differentiate the pre-operative and post-operative diagnoses. For instance, a pathology report can provide additional details that allow for a more precise post-operative diagnosis. You may also wish to report any underlying co-morbid conditions that can affect the surgical outcome

John Verhovshek
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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 “Operative Note Documentation Basics”

  1. Candace Hummel says:

    Where did you get the above information? I would like to reference it.