Patricia Gaddis, Director of Operations

10 Key Must Haves for a Great Operative Note Template.

By Patricia Gaddis, Director of Operations

We're often asked "what's the best way to develop templates for operative reporting?" In this article, we'll sum up what experience has shown to be the 10 Key Must Haves for a Great Operative Note Template.

1. Patient Demographics- Who?

  • Patient Name
  • DOB
  • MRN

2. Date Of Service- When and Where?

  • Date of the Procedure
  • Where the Procedure was performed

3. Date Of Service- When and Where?

  • Co-surgeon ( i.e Vascular)
  • Assistant Surgeon ( P/A or N/P assistant)
  • Resident and/ or Fellow
  • Document The role and medical necessity of any co-surgeon or assitant
  • If you work at a teaching hospital- you need to attest if there was no qualified resident available to assist.

4. Pre/Post-Op Diagnosis-Why?

  • Why are you doing the surgery
  • Be specific
  • Detail
  • Did they have radiculopathy, myelopathy, neuorgenic claudication, instability, foot drop etc.
  • Provide sufficient detail to allow correct selection
  • Include Levels

5. Summary of Procedure-What?

  • List all the procedure that were performed by number and in order of your operative note. This will help your coders to audit your operative note

6. Indications Paragraph- Why?

  • Brief Background on Patient
  • What conservative care has the patient had, i.e physical therapy, pain management injections, NSAIDs etc.
  • Was it a work injury or auto accident?
  • Support the medical necessity of the surgery!

7. Findings Paragraph-What?

  • List what you found
  • What did you remove

8. Main Body of Report

  • If it doesn't appear here, it didn't happen
  • Get it right the First Time
  • Document the reasons the procedure performed differs from prior authorized procedures
  • Any complications?
  • Include the brand Names of the implants or instrumentation used
  • Details, explain in detail the procedure and where it was done.
  • Include levels and what side was the procedure done, right, left or bilateral if applicable.
  • What was the approach and type?- Anterior, posterior, retroperitonal?
  • What type of decompression- discetomy, laminectomy, facetectomy, corpectomy, osteotomy or fracture care- and document the levels?

9. Medical Necessity of Assistant

  • Why was the assistant medically necessary?

10. Treating Physician Attestation

  • Need to certify that you were present
  • Need to sign every single operative note and time stamp

 

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