HIM Module OperativeNote Activity 360 Two Template
Name: [Insert Your Name Here]
In operative notes, there are several components that must completed a physician order accurately code the be by in to
procedure. The Joint Commission has set standards that establish what needs included to be in an operative note, well as
as the time frame which in it must be completed: The report must be written or dictated immediately after operative or an
other high-risk procedure. An organization's policy, based on state law, would define the time frame for dictation and
placement the medical in record. The content within the report must carefully read the medical coder, the be by as name
of the procedure provided the physician by is is not always the same what as described within the description the of
procedure.
In this exercise, you will review each of the operative notes, making sure components missing, no are and you will
accurately assign the most appropriate ICD- -PCS procedure 10 codes.
Note: Save this document using the following naming convention to ensure that you receive proper credit for this
assignment: LastName_him360_module_two_operative_note_activity.
Patient
21A
22A
23A
24B
25C
26C
27C
Date of Procedure
Yes
f f f Yes
Yes
Yes
Yes
Yes
Yes
Surgeon Name
Yes
f f f Yes
Yes
Yes
Yes
Yes
Present on Admission
Yes
f f f Yes
Yes
Yes
Yes
Yes
Yes
Preoperative Diagnoses
Yes
f f Yes
Yes
Yes
