MCCG262 Professional Coder Practicum Documentation Presentation (Medical Billing and Coding)
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SURGEON Addendum
Related encounter: Admission (Discharged) from 3/19/2014 In
MRN
Surgery Brst/Mela/Sarc/Endoc
Of-{o
Sex
Female
H&P
DOB
Page 1 of 3
Age
57
Service date: 03/19/2014 6:54 AM
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Department of Surgery Interval History and Physical Note
Admission Date and Time: 3/19/2014 5:57 AM
Preoperative Diagnosis: invasive ductal carcinoma of the right breast ,,
Pertinent laboratory tests: hct 44, Cr 0.8, INR 1.0
Procedure: Right segmental mastectomy with sentinel lymph node biopsy, and breast reconstruction
Surgeon:
Specific counseling: given in clinic
H&P documentation: I have examined the patient and there have been no interval changes in the patient's medical condition since the H&P was done.
3/19/20146:56 AM
Cancer Follow Up
DIAGNOSIS: Newly diagnosed Stage Ila right breast invasive ductal carcinoma -ER/PR 99% Her 2 Neu
negative per IHC
DATE DIAGNOSIS (MONTH/YEAR): 3/2014
DATE OF SURGERY (MONTH/YEAR): Scheduled
HISTORY: This 57 y.o. y/o woman returns for surgical planning. Ms. initially presented with
a screened detected right breast invasive ductal carcinoma, tumor marker profile pending at that
time. She denied any palpable masses, nipple discharge, skin changes, or axillary adenopathy. Due to
breast density it was recommended that she undergo breast MRI. She presents today for surgical
planning. She has no new complaints.
She has no other n _ 7w medical problems and has not started new medications. Her current medication
(s) are: has a current medication list which includes the following prescription(s): calcium carbonate
and levothyroxine.
PHYSICAL EXAMINATION:
This is a well-nourished, alert and oriented woman. Both nipples are everted without discharge. Due
to breast density there is no discrete dominant mass palpable. There is no focal nodularity or on
either side. She does have well healed reduction mammoplasty scars on both breasts. The abdomen is
8/14/2014
.. ..
soft, flat and nontender, without palpable masses or organomegaly.
IMAGING:Findings:
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Right breast: Centered directly posterior to the nipple (12 o'clock, Zone 2/3) in the right
breast there is an enhancing, irregular mass that measures 2.8 (AP) x 1.5 em in axial
dimensions. The mass measures 1.8 em in cranial caudal dimension. The mass is located
approximately 5.2 em posterior to the nipple and is 3 em deep to the superior skin on the sagittal views.
There is a background of fibrocystic change throughout the right breast with scattered
nonspecific foci of enhancement. There are no suspicious right axillary lymph nodes.
Left breast: There are scattered fibrocystic changes, with scattered nonspecific foci of
enhancement throughout the left breast, without enhancing mass lesion. There are no suspicious
left lymph nodes.
Impression:
Right breast: Enhancing mass in the right breast as detailed above compatible with the
patient's biopsy-proven invasive ductal carcinoma. A second site of disease within the right
breast is not identified. There are no suspicious right lymph nodes on MR imaging .
Background fibrocystic change.
Left breast: Scattered fibrocystic change in the left breast without suspicious mass lesion.
Recommendation : Continued management by the clinical breast team as previously scheduled.
Note: A normal does not exclude the presence of invasive lobular carcinoma or cancers
less than 3 millimeters in size. does not replace mammography and should be used as an
adjunct to annual mammography and physical exam as necessary.
6
diagnosed lla right breast invasive ductal carcinoma 99% Her 2 Neu negative per
reviewed the natural history and evolution of breast cancer were discussed with Ms. : and her husband, including the difference between in-situ and invasive carcinoma, and the distinction between local and systemic disease and local and systemic therapy. For local treatment options, explained the risks and benefits of breast conservation and mastectomy with or without reconstruction, including the fact that survival rates are equal with these two approaches. breast conservation is elected, explained the need for free margins, the of re-excision to achieve free margins, and the need for post-operative radiotherapy. explained that based on her she is a breast conservation candidate. did discuss with her the role of oncoplastic surgery to assist with cosmetic outcomes post radiation therapy. explained that due to her tumor size she require a fairly large excision that leave her with a void of breast tissue. explained that Dr. discuss with her options for both therapeutic mammoplasty at the time of surgery
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.. Page 3 of 3
as as reconstruction post mastectomy if she were to to undergo mastectomy. She that she wanted to undergo breast conservation with approach. We discussed both immediate and therapeutic in regards to margin positivity. She understands
that if she to undergo immediate treatment that a mastectomy may be required if her margins return positive.
The approach to staging was re-described, the technique, risks and benefits of node biopsy, the need for dissection, and the of this
procedure.
With regard to systemic therapy, recommendation be made receipt of post-op, but the of endocrine therapy and chemotherapy depending
on her stage.
this discussion, where of the patient's questions were answered, we agreed to proceed
with Ultrasound guided segmental mastectomy, SLNB, with therapeutic mammoplasty.
This encounter 45 minutes and> 50%was devoted to a discussion of management options.
given opportunity for questions and those questions were answered to her satisfaction. She has been encouraged to contact the office with any questions/concerns prior to her next appointment.
MD
Department of Surgery
saw and the patient. Discussed with resident and agree with resident's findings and as documented in the note. Plan: Right wire localized segmental mastectomy, sentinel lymph node biopsy, and possible reconstruction with Dr.
Department of Surgery
Revision History ...
Date/Time User Action 12:58 Addend
12:58 Cosign
View ReQorl
Routing History ...
Date/Time From To Method 12:58 In Basket
8/14/2014
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MRN
MD Signed
.Related encounter: Admission (Discharged) from 3f19/2014 in r
Sex Female
OpNote
DOB
Page. l of2
Age 57
Service date:
.......... .................... -.................... ,_ .................. .......
PATIENT NAME: MRN: DATE OFSERVICE: 03/19/2014
PREOPERATIVEDIAGNOSIS: Right breast mass.
POSTOPERATIVEDIAGNOSIS: Right breast mass.
OPERATIONPERFORMED: of the right breast defect.
SURGEON: . MD ASSISTANTSURGEON: MD
ANESTHESIA:
IVFLUIDS: ml.
ESTIMATEDBLOODLOSS: ml.
FINDINGS: Excision of right breast mass from the 11 position .
SPECIMENS: Right breast mass; mastectomy skin.
DRAINS: None.
COMPLICATIONS: None.
DISPOSITION: to the Day Surgery Unit and extubated.
INDICATIONSFORPROCEDURE: The patient is a with an extensive history her breasts prior mastopexies as as breast augmentation. The patient presented to my with a diagnosed right breast mass to discuss breast conservation therapy and therapeutic The patient stated that she had a strong interest for a reduction procedure . was to her, at that time, that given the prior surgeries and
she be at very high risk for therapeutic and may require a graft, and may fat necrosis over the inferior We quoted her at that time a risk of the above occurring . We discussed doing no reduction excision of the tumor based on intraoperative findings. risks were discussed with the patient infection, scarring, asymmetry, change in sensation, contour deformity, sensation of extensive fat necrosis and need for eventual mastectomy. The consented to the above.
DESCRIPTIONOFPROCEDURE: The patient was brought to the Preoperative area. The patient was marked for an inferior Wise pattern reduction. note, the was set at 22 em . this manner, a standard pattern was then drawn. The patient was then brought to the Room. The patient was placed supine on the operating room table. A stop time-out was performed. Ancef antibiotics were given within minutes of incision. The chest was prepped and draped in the standard fashion.
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The procedure began with a sentinel lymph node biopsy, per Dr. review her operative notes for this portion of the procedure. We then decided to begin with a lateral extension of the Wise pattern to approach the mass. assisted Dr. . _ in this approach using the lateral extension of the Wise pattern. The mass was then localized, per Dr. , and excised down to the chest wall. note, we did enter the patient's prior capsule at this and it became clear that the patient's capsule extended throughout the inferomedial aspect of the breast above the pectoralis muscle. At this time, it begin evident that a superomedial pedicle would not be feasible. then stepped out and discussed this with the patient's husband and explained our intraoperative findings. He agreed with proceeding with primary closure. For that reason, undermined the breast tissues cephalad above the pectoralis muscle as well as freeing the breast tissue from the overlying dermis. then backcut the breast parenchyma creating a flap measuring 6 x 6 x 6 ern and rotated the breast tissue into the defect and closed this using dyed to doing this, did irrigate the pocket with lrricept solution and obtained meticulous hemostasis. then de-epithelialized an area of the lateral breast tissues to provide a minor left laterally to help with the coning of the breast. The skin was then closed primarily. Similarly, the sentinel node site was irrigated and closed in multiple layers using and Monocryl. The sites were dressed with bacitracin and Xeroform, dry sterile dressings, and Tegaderm. The patient was placed into a surgical bra. Fluffs were placed.
The patient tolerated the procedure without any complications. instrument, sponge and lap counts were correct at the end of the case. The patient was transferred to the in stable condition, extubated. was present for the entire plastic surgery portion of this procedure including the opening and closing.
MD
DD: 12:46 DT: Job#:
Last signed MD by: AM]
Revision History ...
Date/Time AM
5:39AM
View Details Report
about: blank
User
Edit
Action
8/14/2014
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Registered RN Nurse Signed
encounter: Admission !Discharged) from 3/19/2014 in
..
MRN
Care
Sex Female
Progress Notes
DOB
1 of 1
Age 57
date:
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awake and signs and at reports pain po intake without n/v. After care teaching and discharge instructions reviewed with patient and husband. Understanding Mastectomy bra in dry and intact. transferred via
to car.
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MU Physician
DATE: 3/19/2014
MRN
Radiology
Department of Division of Breast
Procedure Note
PRE-OP right breast
same
guided right breast wire
Sex
Progress Notes
TYPE I Lidocaine 1 %without epinephrine
/
1 of 1
Age 57
Service date:
Dense breast tissue, dense mass. to get into mass. 19.5 em wire with 15.5 em out, 4 em in breast. Wire tip positioned to which is extends 17 mm to and 2.5 em posterior to clip. Positioned discussed with at the time of Position is adequate for her needs.
none
n/a
.
case . was present for and participated for the entire procedure. A resident participated in this
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M ed1catron A d . R eport or as off 1 Day 3 Days 7 Days Days
Medications Completed Medications
Medications immediate
release tablet mg (10 mg Freq : Route: mg)
1332 End: Admin Instructions:
1345
**Look- Alike / Alike Alert, Use
Discontinued Medications Medications
infusion 0644
Rate: Freq: Route: End: 2252 1415
infusion Rate 10 Freq : Route -
End: 2252 ,'• acetaminophen 10 MG/ML
End: 2252 . Admin Instructions:
by cabinet override
albumin human 5 % bottle End: 2252
Admin by cabinet override
injection mg Dose: mg Freq: Route .
Reason: other Comment For moderate to severe pain (pain rating of 5 or greater.
1257 End: 1341 Admin Instructions: ' . .
May give every 4 minutes .. ,. to exceed 2 mglhr in Hold for resp less
: than 12, less than 92%, NN, sleep. ' **Look -Alike - Alike Alert Use
(LMX 4) 4 '1 . kit
'
2 ml . Dose:2 -
Reason: other Comment: for pain at .
End: 2252 (NARCAN) injection mg
Dose meg Freq: Route . Reason: other . Comment: Resp less than 1 and less than on .
1257 End: 1341 . El Admin Instructions: Begin mask ventilation and prepare to intubate. : -
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Anesth May repeat X 1
ondansetron (ZOFRAN) injection 4 mg Dose: 4 mg Freq: Route:
Reasons: nausea,vomiting
03/19/14 1257 End: 03/19/14 2252
Medications o311o 03/11 03/12 03/13 03/14 03/15 03/16 03/17 03/18 03/19
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