Forum - Questions & Answers

Jun 20th, 2011 - marielewis

need documentation requirements for operative note

Can anyone point me in the right direction as to where I might be able to find a document which spells out documentation guidelines and format for an op note. I have been looking all day and haven't found a reputible web site that can help me. I was trained to always code by the body of the note, not what is in the heading of the note. The training information I have on how to code an op note isn't from AAPC. I couldn't find anything in my Curriculum Workbook to help me. The heading of the note includes the diagnosis of lesion and location of it on the patient. This information isn't found anywhere in the body of the note.

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Jun 20th, 2011 - DebraS   67 

re: need documentation requirements for operative note

Our docs have at the top of the op note the patients name/dob of course. Then date of procedure, pre-dx and post-dx along with actual procedure performed (including levels, muscles, etc). Then they dictate the actual op note information below that and describe their procedures and last but not least, how the patient tolerated the procedure and if any difficulties/complications/other issues. I even have a doc that when he uses a -22 modifier, he even dictates the length of time exceeding his normal time and all the why's that are needed. Sometimes it works, sometimes it doesn't.

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Jun 20th, 2011 - jschmutz   323 

re: need documentation requirements for operative note

The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) sets standards for healthcare organizations and issues accreditation to organizations that meet those standards.

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 most important issue is that there needs to be enough information in the record immediately after surgery in order to manage the patient throughout the postoperative period. This information could be entered as the operative report or as a hand-written operative progress note.

If the operative report is not placed in the medical record immediately after surgery due to transcription or filing delay, then an operative progress note should be entered in the medical record immediately after surgery to provide pertinent information for anyone required to attend to the patient. This operative progress note should contain at a minimum comparable operative report information. These elements include;

the name of the primary surgeon and assistants
procedures performed and description of each procedure findings
estimated blood loss
specimens removed
post operative diagnosis.

Immediately after surgery is defined as "upon completion of surgery, before the patient is transferred to the next level of care". This is to ensure that pertinent information is available to the next caregiver. In addition if the surgeon accompanies the patient from the operating room to the next unit or area of care, the operative note or progress note can be written in that unit or area of care.

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Jun 20th, 2011 - jschmutz   323 

re: need documentation requirements for operative note

Formal Operative Report

The formal operative report is where the complete documentation of the procedure should be found. A complete operative report should always include the following:

  1. Date and time of the procedure

  2. Pre- and post-operative diagnoses

    1. The preoperative diagnosis is most useful from a coding standpoint when the postoperative findings are inconclusive. The indications, signs and/or symptoms listed in the preoperative diagnoses will support the medical necessity of the service.

      1. Example: A patient presents to the ED with severe right lower quadrant pain, fever, and nausea. Exploratory laparoscopy reveals normal appendix, normal ovaries and tubes, normal ileum and cecum with no signs of blockage, inflammation, purulence, or trauma. No significant adhesions.

      2. Procedure will be billed as 49320 (diagnostic laparoscopy). Diagnoses to support the need for the service will be RLQ pain, fever, nausea.

    2. Do not include ICD-9 codes in the operative note as this would require amendment if a different diagnosis code was selected for billing

  3. List all procedures performed

    1. A clear list of procedures performed is an expected component of the operative report and is very helpful from a coding and reimbursement standpoint as there are sometimes details found in this list that do not show up in the subsequent documentation. Additionally, as a concise statement of the services provided this list can become a roadmap for interpreting the body of the note, particularly if there are difficulties, altered anatomy or transcription errors that add to the complexity of interpreting the documentation.

    2. CPT® codes should not be listed in the operative note. This documentation may subsequently be provided to other physicians, attorneys, insurers, or to the patient him/herself. CPT® codes are essential billing information and are not appropriately part of that record.

      1. Additionally, if the CPT® code included in the record does not end up being the CPT® code billed, this would necessitate extra work for the physician to amend the record with the corrected code.

  4. Type of anesthesia used is often documented in the operative note. It is typically not a key component from a coding standpoint but may appropriately influence patient care.

  5. Blood loss/Blood Replacement is also often documented as part of the operative report as well as other places in the operative record (e.g., the anesthesia record) and may be valuable for patient care. This does not have an impact on coding and reimbursement.

  6. All surgeons who participated in the case must be listed in the operative note. This includes resident physicians as well as staff surgeons. If there is a change of primary surgeon during the case for any reason, this should be indicated including the point at which the change took place.

    1. In best practice the roles of each surgeon would also be indicate (e.g., primary surgeon, assistant surgeon, cosurgeon)

  7. As discussed above, it is necessary for the indications for the procedure to be documented somewhere in the note. It is not necessary for it to be a separately identified element of the note, although it can provide helpful information if subsequent problems arise.

  8. Findings are another element that does not have to be separately documented but which can be very helpful. As described above, this summary information is an excellent place to document unexpected findings, the size of tumors or lesions, complications, extra work involved in the procedure and other key information that can have an impact on patient care and can also help in coding and reimbursement.

  9. The procedure description should be as specific as possible and should include the patient’s position, the approach or approaches used, the specific organ, structure, or area being operative upon (e.g., don’t just say the vein was canulated, specify which vein).

    1. It may be appropriate in some circumstances to document that a procedure was performed in the “standard fashion” or “per protocol” but without details this cannot be substantiated should it come under question by a patient with a bad outcome.

      1. Additionally, this documentation will not support the performance of additional separately billable procedures that would be performed “per protocol”.

    2. Be specific in your documentation. It cannot be assumed that something was performed simply because it is the way the procedure is usually done. Just as unusual approaches and findings must be specifically documented, so must standard approaches and findings.

    3. If something was removed from the patient’s body (e.g., hysterectomy) it is important to not only document that the ligments and blood vessels and other attachments were ligated, cut and that the organ was freed up for removal, the note should also document the removal itself.

  10. Signatures

    1. Everyone who documented any part of the operative note should sign the record. It should be possible to identify who documented each element of the note and, if any changes or amendments were made, who made them and when.

    2. The note should be read before it is signed. This process will find errors and inconsistencies before the document is finalized.

      1. This is particularly important for dictated documentation as transcription errors can have a significant impact on patient care as well as medicolegal implications and possible ramifications for billing and reimbursement.

      2. Consider the very simple transcription error of the different between the words “not” and “now”. For example, “A biopsy was not done” versus “A biopsy was now done”. Accurate documentation includes careful proofreading.

  11. Teaching physician documentation is required on all operative notes when a resident was present during the procedure.

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Jun 21st, 2011 -

re: need documentation requirements for operative note

What is the name of the source you obtained this information? I have been able to print a copy of both acceptable and unacceptable operative reports from JCAHO's website, but I have not been able to find the actual stated requirements listed out. I found some information on the University of Washington Physicians Education under Compliance. My doc wants a more credible source like AMA, JCAHO, CMS. Thank you to all who replied for your help.

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Jun 22nd, 2011 - jschmutz   323 

re: need documentation requirements for operative note

I suggest you go the library and check out this book and show it to your physician. Medical Legal Aspects of Medical Records By Patricia W. Iyer, Barbara J. Levin, Mary Ann Shea.

All my bookmarks related to the JCAHO are no longer active and I can't find their standard operative documentation standards (weird).

The federal register gives some direction on medical record documentation (starts on page 59439):

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Jun 22nd, 2011 -

re: need documentation requirements for operative note

Thank you sooooo much.

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Jul 22nd, 2011 -

re: need documentation requirements for operative note

JCAHO Standard IM.6.30
Element of Performance (EP 3) details data elements for the dictated operative
IM.6.30 EP3 Operative reports (dictated) immediately after a procedure must
record the:
IM.6.30 EP3 Name of primary surgeon & assistants
IM.6.30 EP3 Findings
IM.6.30 EP3 Procedure(s) performed
IM.6.30 EP3 Description of procedure
IM.6.30 EP3 Estimated blood loss, as indicated
IM.6.30 EP3 Specimens removed
IM.6.30 EP3 Post-operative diagnosis

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Aug 19th, 2013 - draer1119 2 

re: need documentation requirements for operative note

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Aug 19th, 2013 - nmaguire   2,606 

re: need documentation requirements for operative note

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Oct 17th, 2013 -

re: need documentation requirements for operative note

Here is the documentation requirement for the operative note.

(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)

§482.51(b)(6) - An operative report describing techniques, findings, and tissues removed or altered must be written or dictated immediately following surgery and signed by the surgeon.

Interpretive Guidelines §482.51(b)(6)
The operative report includes at least:
• Name and hospital identification number of the patient;

• Date and times of the surgery;

• Name(s) of the surgeon(s) and assistants or other practitioners who performed surgical tasks (even when performing those tasks under supervision);

• Pre-operative and post-operative diagnosis;

• Name of the specific surgical procedure(s) performed;

• Type of anesthesia administered;

• Complications, if any;

• A description of techniques, findings, and tissues removed or altered;

• Surgeons or practitioners name(s) and a description of the specific significant surgical tasks that were conducted by practitioners other than the primary surgeon/practitioner (significant surgical procedures include: opening and closing, harvesting grafts, dissecting tissue, removing tissue, implanting devices, altering tissues); and

• Prosthetic devices, grafts, tissues, transplants, or devices implanted, if any.

Survey Procedures §482.51(b)(6)
Review a minimum of six random medical records of patients who had a surgical encounter. Verify that they contain a surgical report that is dated and signed by the responsible surgeon and includes the information specified in the interpretive guidelines.

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