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RE: Operative reports
a) Operative records shall include a statement of indication for surgery, a detailed account of the findings at surgery, technical procedures used at surgery, estimated blood loss, the specimens removed, the postoperative diagnosis, and the name of the primary surgeon and assistant(s).
Correspondingly, how do you code an operative report?
Operative Report Coding Tips. Diagnosis code reporting—Use the post-operative diagnosis for coding unless there are further defined diagnoses or additional diagnoses found in the body of the operative report. If a pathology report is available, use the findings from the pathology report for the diagnosis.
In this manner, when should the operative report be dictated?
A: The operative 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 timeframe for dictation and placement in the medical record.
The largest section of the OP report is the procedure note. This is where the physician documents the specifics of what he or she did. The physician should clearly outline all procedures performed and provide details, including: Patient position. Approach.