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The documentation:
Why is the abscess not coded?
OPERATIVE REPORT
SEX: MALE
AGE: 70
DATE OF OPERATION: 1/1/20XX
PREOPERATIVE DIAGNOSIS: SECOND TOE GANGRENE.
PROCEDURES: LEFT SECOND TOE I&D OF THE ABSCESS OF BONE.
POSTOPERATIVE DIAGNOSIS: SECOND TOE GANGRENE PLUS ABSCESS OF THE FOOT.
SURGEON: ALEXANDER Jones, M.D.
ANESTHESIA: ANKLE BLOCK.
ESTIMATE BLOOD LOSS: MINIMAL.
COMPLICATIONS: NONE.
INDICATIONS: A 70-year-old male well known to vascular service due to bilateral lower extremity, peripheral vascular disease, status post left SFA recanalization and stenting a few months ago due to first toe ganglion. Postoperative wound was healing however second toe demonstrated present some recurrent bones of infection. Therefore decision was made to proceed with debridement of the second toe.
PROCEDURE: The patient was brought to OR and placed on OR table in supine position. Ankle block was administered by anesthesiologist. Left lower extremity was prepped and draped for sterile procedure. Skin incision was made around base of the second toe and continued through the skin and subcutaneous tissue down through the bone. At this point, we entered into the abscess cavity at approximately 10 cc of gross pus was removed. Appropriate cultures were taking and send out. Using bone cutter second proximal metatarsal bone was transsected and rongeured. All the necrotic tissues were debrided. The wound was irrigated copiously with antibiotic solution. Good bleeding from the skin edges and the bone was covered with two 3-0 Vicryl stitches which were approximated fascial layer over the bone. The rest of the wound was left open and packed with Betadine strip. 4 x 4 Kerlix roll applied as a dressing. The patient tolerated the procedure. He was alert and awake at the end of the procedure safely and then transported to the recovery room for further management.
Alexander Jones, MD
Electronically signed by ALEXANDER JONES, MD 10/3/20XX
SEX: MALE
AGE: 70
DATE OF OPERATION: 1/1/20XX
PREOPERATIVE DIAGNOSIS: SECOND TOE GANGRENE.
PROCEDURES: LEFT SECOND TOE I&D OF THE ABSCESS OF BONE.
POSTOPERATIVE DIAGNOSIS: SECOND TOE GANGRENE PLUS ABSCESS OF THE FOOT.
SURGEON: ALEXANDER Jones, M.D.
ANESTHESIA: ANKLE BLOCK.
ESTIMATE BLOOD LOSS: MINIMAL.
COMPLICATIONS: NONE.
INDICATIONS: A 70-year-old male well known to vascular service due to bilateral lower extremity, peripheral vascular disease, status post left SFA recanalization and stenting a few months ago due to first toe ganglion. Postoperative wound was healing however second toe demonstrated present some recurrent bones of infection. Therefore decision was made to proceed with debridement of the second toe.
PROCEDURE: The patient was brought to OR and placed on OR table in supine position. Ankle block was administered by anesthesiologist. Left lower extremity was prepped and draped for sterile procedure. Skin incision was made around base of the second toe and continued through the skin and subcutaneous tissue down through the bone. At this point, we entered into the abscess cavity at approximately 10 cc of gross pus was removed. Appropriate cultures were taking and send out. Using bone cutter second proximal metatarsal bone was transsected and rongeured. All the necrotic tissues were debrided. The wound was irrigated copiously with antibiotic solution. Good bleeding from the skin edges and the bone was covered with two 3-0 Vicryl stitches which were approximated fascial layer over the bone. The rest of the wound was left open and packed with Betadine strip. 4 x 4 Kerlix roll applied as a dressing. The patient tolerated the procedure. He was alert and awake at the end of the procedure safely and then transported to the recovery room for further management.
Alexander Jones, MD
Electronically signed by ALEXANDER JONES, MD 10/3/20XX
Why is the abscess not coded?