Components of an operative report:
[LIST][*]Preoperative diagnosis - tentative diagnosis before surgery[*]Postoperative diagnosis - diagnosis after the surgery has been performed[*]Surgical procedure - concise statement of the procedure(s) performed[*]Indications for procedure - facts leading up to the decision for the surgery[*]Details of procedure - narrative detailed description of the surgical procedures[*]Signature of surgeon
Common Procedural Terms of Method or Technique:
Also pay attention to the approach for example: Did the surgeon access surgical site throught the umbilical or the thoracic?
Sample of questions to ask yourself to help determine a code (for example, removal of a lesion):
- Was the lesion benign or malignant?
- What technique was used to remove the lesion (laser, excision, or shaving)?
- Where was the lesion?
- Were there any additional procedures performed, such as intermediate wound closure?
- What was the excised diameter (greatest clinical diameter) of the lesion?
I could go on and on but I would probably be typing for hours. Pay strict attention to the guidelines for sequencing and modifiers.
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