HIM Module 360 Two Operative Note Activity Template
Name: [Insert Your Name Here]
In operative notes, there several components that must completed a are be by physician in order accurately to
code the procedure. The Joint Commission has set standards that establish what needs included to be in an
operative note, well the time frame which must completed: The report must written dictated as as in it be be or
immediately after an operative or other high-risk procedure. organization's policy, based An on state law, would
define the time frame for dictation and placement the medical record. The content within the report must in be
carefully read the medical coder, the name the procedure provided the physician not always the by as of by is
same what described within the description the procedure. as is of
In this exercise, you will review each the operative notes, making sure components missing, and you of no are
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
m m m Yes
Yes
Yes
Yes
Yes
Yes
Surgeon Name
Yes
m m m Yes
Yes
Yes
Yes
Yes
Present on Admission
Yes
m m m Yes
Yes
Yes
Yes
Yes
Yes
Preoperative Diagnoses
Yes
m m Yes
Yes
Yes
