HIM Module OperativeNoteActivity 360 Two Template
In operativenotes,there are several components that must completed be by aphysician in order accuratelycode to the
procedure. The Joint Commission has set standards that establish what needs to be included in an operative note, as well as
thetimeframe in which must it be completed: Thereportmust written be or dictatedimmediately after an operative or
other high-risk procedure. An organization'spolicy,based on statelaw, would define the time framefor dictation and
placement in themedical record. The content within the report must be carefully read the by medical coder, the as name of
theprocedureprovided by the physician is notalways the same what as is described within thedescription of the
procedure.
In this exercise,you willrevieweach of the operativenotes, makingsure no components missing,andyou are will
accurately assign the mostappropriate ICD- -PCSprocedure 10 codes.
Note: Savethis document using thefollowing 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
l l l Yes
Yes
Yes
Yes
Yes
Yes
Surgeon Name
Yes
l l l Yes
Yes
Yes
Yes
Yes
Present on Admission
Yes
l l l Yes
Yes
Yes
Yes
Yes
Yes
Preoperative Diagnoses
Yes
l l l Yes
Yes
Yes
Yes
