Forum - Questions & Answers

Aug 23rd, 2010 - jschmutz   323 

Operative Report Documentation

Does anyone know of any legal requirements as to what needs to be documented in an op-note? Is this something each facility/hospital decides?

I have a few providers that severely lack in documentation and I can find "recommendations" of what should be included but nothing in black and white that says, if you don't have at least this, then your document is not legal.

Here is an example of an op-note:

PRE-OP DX: subcapital fracture of left hip. Pt is debilitated female with very poor skin turgor.


Fracture table. Lateral Approach. Three cannulated 713 Synthes screws. Image controlled. Estimated blood loss less than 10. Count correct. No complications. 0 Vicryl subcutaneous staples skin.

That is the entire op-note, and it is consistent with all of their op-notes. Telling them what SHOULD be documented doesn't seem to make a difference. I'm hoping there is something that states what MUST be documented, that way I can tell them we can't code it or submit it for billing because the documentation requirements have not been met.

Any help would be appreciated.

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Aug 23rd, 2010 -

Documentation requirements for operative procedures

The Federal Register ( ) indicates that the physician must: describe techniques, findings, and tissues removed or altered must be written or dictated immediately following surgery and signed by the surgeon.

When I've had questionable operative reports I've asked the surgeon if they are comfortable supporting their work in court should they be called upon to clarify their documentation. I would not be comfortable, if I was a surgeon, supporting that operative procedure you used as an example, but then again, I'm not a surgeon.

If you look on CMS' site ( you will be able to find CERT findings where 1.9% of the claims reviewed lack complete documentation of procedures performed, thus monies are being taken back.

I hope this helps.

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Jul 22nd, 2011 -

re: Operative Report Documentation

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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