I cannot code a procedure for either of these "complete" notes.
An operative / procedure note needs to have:
Patient identifiers (obviously you wouldn't post that here)
Date of service
Postoperative diagnosis if different
Title of procedure
Description of procedure performed - location and type of incision, instrumentation, findings, closure, etc
Anesthesia / analgesia used
Condition/disposition of patient at end of procedure
Name and signature of provider
Hope that helps.
F Tessa Bartels, CPC, CEMC
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