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HIM 360 Module Two Operative Note Activity Template
In operative notes, there are several components that must be completed by a physician in order to accurately
code the procedure. The Joint Commission has set standards that establish what needs to be included in an
operative note, as well as the time frame in which it must be completed: The report must be written or
dictated immediately after an operative or other high-risk procedure. An organization's policy, based on state
law, would define the time frame for dictation and placement in the medical record. The content within the
report must be carefully read by the medical coder, as the name of the procedure provided by the physician is
not always the same as what is described within the description of the procedure.
In this exercise, you will review each of the operative notes, making sure no components are missing, and
you will accurately assign the most appropriate ICD-10-PCS procedure 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
bb bb bb Yes
Yes
Yes
Yes
Yes
Yes
Surgeon Name
Yes
bb bb bb Yes
Yes
Yes
Yes
Yes
Present on Admission
Yes
bb bb bb Yes
Yes
Yes
Yes
Yes
Yes
Preoperative Diagnoses
Yes
bb bb bb Yes
Yes
Yes
Yes
Yes
Yes
Postoperative Diagnoses
Yes
bb bb bb Yes
Yes
Yes
Yes
Yes
Anesthesia
Yes
bb bb bb Yes
Yes
Yes
Yes
Yes
Procedure
Yes
bb bb bb Yes
Yes
Yes
Yes
Yes
Estimated Blood Loss
Yes
bb bb bb Yes
Yes
Yes
Complications
Yes
bb bb bb Yes
Yes
Yes
Yes
Findings/Specimens Removed
Yes
Yes
Indications
Yes
bb bb bb
Yes
Yes
Yes
Description of Procedure
Yes
bb bb bb Yes
Yes
Yes
Yes
Yes
Yes
Physician Signature and Date
Yes
bb bb
Yes
Yes
Yes
Yes
Patient
21A
22A
23A
24B
25C
26C
27C
Report:
After the review of the patient’s charts, it was found that there were missing elements in them. Every
chart had missing pieces of documentations that were required. For example, Charts 27C, 26C, 24B, 23A,
and 22A did not have identification of specimen or findings removed. Charts 22A and 26C did not have
date and physician’s signature. Chart 26C was also missing other documentation elements like the
performed procedures, even though its description was provided. All the charts contained the dates relating
to procedures which are a good sign as it can help in billing. The description of procedures was also
available on all the charts. It can aid the billing department to make use of the appropriate diagnosis codes
when it comes to insurance guidelines as well as patient billing. All the reports missed the mark during
auditing since they did not comply with all the set standards.
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