HIM 360 Module Two Operative Note Activity Template
Name: [Marie Brown]
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
Yes
Yes
Yes
Yes
Yes
Yes
Surgeon Name
Yes
Yes
Yes
Yes
NO
Yes
Yes
Present on Admission
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Preoperative Diagnoses
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Postoperative Diagnoses
Yes
Yes
Yes
Yes
Yes
NO
Yes
Anesthesia
Yes
Yes
Yes
Yes
NO
Yes
Yes
Procedure
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Estimated Blood Loss
Yes
Yes
Yes
Yes
Yes
NO
Yes
Complications
Yes
NO
Yes
NO
Yes
Yes
NO
Findings/Specimens Removed
Yes
NO
NO
NO
NO
NO
NO
Indications
Yes
NO
Yes
NO
Yes
NO
Yes
Description of Procedure
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Physician Signature and Date
Yes
NO
Yes
Yes
Yes
NO
Yes
Patient
ICD-10-PCS Codes
21A
0HBU0ZZ
22A
0DBJ4ZZ
23A
OFB44ZZ
24B
0WQF4ZZ
25C
0DJD8ZZ
26C
0SRC069
27C
10D00Z1
Report:
After a thorough review of the patient charts, numerous errors and missing elements were identified.
Missing components in patient charts can lead to significant issues, including delays in billing and reimbursement
approvals. For example, documentation was missing for findings or specimens removed in charts 22 A, 23 A, 24
B, 26 C and 27 C. Additionally chart 26 C displayed disparities between the procedure date and demographic
details. Furthermore, the surgeon's information which was very important was missing in chart 25 C . Both charts
22 A and 26 C had missing signature from the physicians a requirement for validating and authorizing the
documentation. These oversights could lead to delays in processing until the physician verifies and confirms the
information.
To address these issues, it is crucial to prioritize the completeness and accuracy of patient charts before
submitting them for reimbursement claims. I recommend implementing targeted education for staff on the
importance of including all required elements in a patient's chart. Regular audits can also help identify recurring
trends, allowing the organization to focus improvement efforts on specific areas to minimize errors and enhance
documentation practices.
