Health Information Management

Tip: Look to procedure note for operative report details

APCs Insider, September 28, 2012

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The largest section of the OP report is the procedure note. This is where the physician documents the specifics of what he or she did. The physician should clearly outline all procedures performed and provide details, including:

  • Patient position
  • Approach
  • Anatomic site
  • Depth
  • Findings

Physicians don't always specify the approach, but coders can look for certain keywords to tell them what approach the physician used. For example, physicians can choose an open or laparoscopic approach for abdominal procedures. If coders see the words "insufflated abdomen," they'll know the physician is performing a laparoscopic procedure even if the physician doesn't mention a laparoscopic approach-the only reason to insufflate the abdomen is for laparoscopy.

The physician should document any misadventures or complications, as well as any abnormal findings. This is also where the physician should document the time for procedures that require additional work.

The physician should include all of the following in the procedure note, as applicable:

  • Excisions
  • Biopsies
  • Lesions
  • Foreign bodies
  • Anastomoses
  • Tubes placed for drainage or feeding
  • Hardware used as part of repair
  • Grafts
  • Blood loss

The physician should also report the type of closure with enough detail to support any additional coding for an extensive repair.

The tip is adapted from “Coders need to learn to read an operative report” in the July Briefings on APCs.


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