HIM 360 Module Two Operative Note Activity Template
Name: Kimberly Martin
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 Yes No Yes 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
Patie
nt
ICD-10-PCS Codes
21A 0HBU0ZZ
22A 0DTJ4ZZ
23A 0FT44ZZ
24B 0YU50JZ
25C 0DJD8ZZ
26C 0SRC069
27C 10D00Z1
Report:
After reviewing the patient charts, I found numerous missing elements. Incomplete charts can lead to issues with
billing, reimbursement approvals, and more. Ensuring that every part of the chart is documented and accurate is essential.
With that being said, Patients 21A and 23A had complete charts that were well organized and documented. Chart 22A was
missing a few important elements, the most important being a provider's signature and date. Also missing were
complications, findings/specimens removed, and indications. The procedure description was very in depth and informative
and allowed you to fill in the blanks on the specimen removed and the complications. Regardless, those elements still
should have been documented at the beginning of the chart. Patient 24B had a nicely detailed procedure but the chart was
lacking some elements including complications, findings/specimens, and indications were all missing. Chart 25C was
missing the name of the surgeon that performed the procedure though it was noted in his signature at the bottom.
Anesthesia was also missing from this chart but according to the detail of procedure, the patient did in fact receive a form
of anesthesia.
26C was missing quite a few critical elements for a complete chart. Post Op diagnosis is missing and very important
because it is the surgeon's final assessment of the patient after surgery. The Post Op diagnosis is necessary for proper
billing and coding as reimbursement depends on this code. Other missing elements are estimated blood loss, indications,
findings/specimens removed, and the physician's signature and date. Missing the physician's signature can cause issues
since the information is not approved until the physician states that everything is correct. Chart 26C also had differing
dates in the procedure date versus the demographic information. I noted that the procedure date was not missing, but was
unclear which date was correct. This could not be confirmed based on the missing providers signature and date/time
stamp. Patient 27C had a mostly complete chart but did have some missing information which included complications and
findings/specimens removed. The chart layout was easy to read and was documented well with the exception of the
missing elements. While it can be assumed that there were no complications based on the detail of procedure,
documenting that element is still necessary and would only require a “none” response. The same should be applied to the
specimen section.
Accurate and complete operative notes are important for quality patient care and proper billing. Any missing
information can result in billing delays, claim denials, and compromised patient care. They may also be reviewed during
audits, emphasizing the need for complete documentation to protect healthcare providers. Education on the effective use
of electronic health records, coding guidelines, and documentation requirements is important to improve accuracy. All
necessary elements, such as indications, findings, procedure details, and follow-up plans, must be documented to prevent
gaps in records. Ongoing education on compliance standards will help reduce the risk of audits or penalties.
