HIM 360 Module Two Operative Note Activity Template
Name: Jennifer King
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 Yes Yes
Preoperative Diagnoses Yes Yes Yes Yes Yes Yes Yes
