ACDIS day2-12 track1-7 pres 0517-Frank Manchenton-f

Anatomy of a Surgical Note:

A CSI Analysis of Operative Notes Gone Bad

Frances Frank, MBA, MSN, HCM, RN, CPHQ, CDI Manager

Stanford Health Care, Palo Alto, CA

Cheryl Manchenton, RN, BSN, Project Manager, Quality Services Lead

3M HIS Consulting, Atlanta, GA

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Disclaimer

This presentation is intended for educational purposes only and

does not replace independent professional judgment. The

statements and opinions expressed are those of the speakers and,

unless expressly stated to the contrary, do not represent the views

or opinions of Stanford Health Care. Stanford Health Care does not

endorse or assume responsibility for the content, accuracy, or

completeness of the information presented.

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Agenda

? CSI investigation: Operative note template analysis and code

assignment

? Meet the defendant: Case example

? The trial

¨C Prosecuting attorney case presentation

¨C Defense attorney case presentation

? The verdict

¨C Judge¡¯s ruling

? The acquittal

¨C Education and collaboration opportunities

? Q&A

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2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved.

These materials may not be copied without written permission.

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Learning Objectives

? At the completion of this educational activity, the

learner will be able to:

¨C Approach review of an operative record to identify

applicable code assignment

¨C Discuss terminology and template usage with surgeons

¨C Identify conflicting information in the operative record

¨C Identify strategies to collaborate to improve quality

outcomes

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CSI Investigation

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Basic Components of an

Operative Note and

Associated Documents

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2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved.

These materials may not be copied without written permission.

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Components of an Operative Report

A. Procedure section

¨C This section contains a listing of the procedure(s) performed. It is very

general. Code assignment should not be dependent on the title of the

report.

B. Diagnosis(es) preoperatively and postop section

¨C Code assignment should not be based solely on what diagnosis(es) are

included in this section. Many times the detailed note has additional

information and diagnoses that need to be coded or information that may

change code assignment.

Potentially three procedure assignments on case

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Components of an Operative Note

C. Detailed operative note section

¨C Every operative note should be read in its entirety to ensure all diagnoses

and procedures contained in notes are captured

¨C Also essential to read entire note to determine whether all procedures and

conditions are clinically significant or whether a clarification should be

placed for significance or to accurately and fully capture the procedure

codes

? Anatomy

? Laterality

? Approach

? Root operation

? Diagnostic vs. therapeutic

? Any device insertions

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Components of an Operative Note

C. Detailed operative note

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2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved.

These materials may not be copied without written permission.

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Components of an Operative Note

D. Findings section

¨C Findings listed may not be noted in the details of the operative report,

especially in cases such as bronchoscopies or other diagnostic procedures

E. Complications section

¨C Note that this is not the sole determination of whether there were

complications. The rest of the medical record and preliminary operative report

(if applicable) should be reviewed.

¨C If there is conflict between this section and other evidence or documentation,

clarification should be placed. Merely denoting ¡°none¡± in this section should

not be used as ¡°proof¡± of no complications.

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Components of an Operative Note

F. EBL (estimated blood loss) section

¨C What is entered in this section is helpful to determine if there are

opportunities to clarify anemia and/or significance of surgical bleeding in

conjunction with preoperative H/H

G. Postoperative condition section

¨C This section is helpful to review for query opportunities for diagnoses such

as hypotension, shock, respiratory issues, possible complications, etc.

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Other Related Operative Documentation

? Don¡¯t forget!!

¨C Anesthesia note

? Preoperative assessment may include medical conditions

not documented by providers that can be captured

? Review for use of pressors, vital signs, fluid boluses, etc.

for possible query opportunities

¨C PACU note

? Review for hemodynamic status, respiratory status,

bleeding, neurologic issues, etc.

¨C Anesthesia postoperative evaluation note

? Review for any adverse effects of the surgery or

anesthesia, etc.

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2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved.

These materials may not be copied without written permission.

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Operative Note Issues

? Variety: Freestyle, templates

? Surgeons have been known to dictate operative

reports at different times. With that comes pros and

cons.

¨C Some ¡°batch dictate¡± at various frequencies, e.g., at the end

of a surgical day, once a week, once every two weeks, once a

month (ouch!), once they receive ¡°nastygrams¡± from

medical record department that they are delinquent (30

days after discharge) (= big ouch!!)

¨C Some dictate after every surgery

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Meet the Defendant:

Low Anterior Resection Case

Example

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First Surgeon¡¯s Procedure Title:

1. Laparoscopic low anterior resection of the rectum with stapled side©\to©\end

descending colon©\to©\rectal anastomosis at 5 cm from the anal verge

2. Laparoscopic mobilization of the splenic flexure

Operative Report Detail Regarding Surgical Approach:

¡°We made a 7 cm suprapubic incision and deepened it into the skin and subcutaneous tissue. This

was taken down to the anterior rectus sheath. The fascia was incised and the peritoneal cavity

entered. A GelPort was placed. With my hand in the abdomen a 10 mm trocar was placed in the

supraumbilical position and a pneumoperitoneum was achieved to 15 mm Hg using carbon dioxide.

Two additional working trocars were placed.¡±

Supports code assignment for laparoscopic

portion of procedures

¡°After freeing up the left colon, our attention was turned to the pelvic dissection. The GelPort was

removed leaving the Alexis retractor in place ... (operative note details rectum removed¡ªsee

subsequent slides)

Supports code assignment for open portion of

procedures

¡°We then replaced the GelPort and reconstituted the pneumoperitoneum¡±

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2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved.

These materials may not be copied without written permission.

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