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Sample Operative Report for Medical coders

PREOPERATIVE DIAGNOSIS: Torn right medial and lateral menisci.

POSTOPERATIVE DIAGNOSES: Torn right medial and lateral menisci, degenerative arthritis of medial femoral condyle, and chondromalacia patella.

Sample Operative Report for Medical coders

PROCEDURES PERFORMED:

DISPOSITION: The patient tolerated the procedure very well.

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OPERATIVE PROCEDURE: The patient was brought to the operating room. He was properly identified and correct extremity was marked. The permit was checked. The patient received 600 mg of IV Cleocin as prophylaxis due to penicillin allergy. General anesthesia was administered and the right knee and right lower extremity were prepped and draped in the usual sterile operative fashion. The pneumatic tourniquet was inflated around the thigh to 350 mmHg pressure. The right knee joint was injected with 50 cc of normal saline. Three standard arthroscopic portals were placed around the right knee in the usual locations, and arthroscopy was carried out in the usual fashion. The medial compartment of the knee was first inspected and probed. There were degenerative changes noted on the medial femoral condyle and there was a complex tear of the posterior horn of the medial meniscus with both the vertical and horizontal cleavage tear. The tear was debrided with the use of basket forceps and a motorized shaver. The under leaflet of the horizontal cleavage tear was debrided back to a stable rim. The loose articular debris was also shaved from the medial femoral condyle. The intercondylar notch was with intact cruciate ligaments. The lateral compartment revealed no significant degenerative arthritis; however, there was also complex tear of the midportion of the lateral meniscus, which was also debrided with basket forceps and a motorized shaver. The patellofemoral articulation revealed grade II chondromalacia of the patella and loose articular debris was shaved from the undersurface of the patella. The knee joint was then suctioned and stab wounds were closed using 4-0 interrupted nylon suture. The knee joint was then injected with 80 mg of Depo-Medrol and 30 cc of 0.5% ropivacaine. Sterile compressive dressing was placed and the patient was reversed from anesthesia and transferred to the stretcher and brought to the recovery room in satisfactory postoperative condition.

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