Hello coders, I decided to add the op note for the surgery. I still need help with a code for this:
The patient was identified in preop holding both verbally and by his
identification tag, transferred to the placed on the OR table in supine
position. Anesthesia gave general anesthetic, secured airway. The
patient's right proximal humerus was then addressed and his arm was
prepped and draped in sterile fashion. Right arm was elevated and
reduction was performed. Acceptable reduction was seen in 2 views. A
2-0 Steinmann partially threaded pin was placed and placed across the
fracture site and prior to the phthisis. Acceptable reduction was seen.
He had stability. another Steinmann pin was made a stab hole anterior
to this and through the stab hole Vita-Gel was placed in the fracture
site for bone healing potential and hemostasis. The patient was stable
with the one Steinmann pin throughout range of motion, both in the AP
and lateral views. At this point, the Steinmann pin was bent, cut, and
pin cap was placed. Xeroform was placed around a sterile dressing
applied. He was transferred to PACU in stable condition. He
will be discharged to follow-up with me in 10-14 days. Keep the
immobilizer on and to be followed orthopedically outpatient.
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