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Mastering the Art of a Perfect Operative Note

19 Jul 2017, Posted by Micah Swihart, CPC-A, ASC Procedural Coder in Healthcare, ASC Billing & Coding, Revenue Cycle Management
Operative Note

In healthcare, the details always matter. And few understand this as well as coders, who rely on every last detail to ensure cases are coded accurately, billed properly and paid quickly. One of their most valuable sources for detail? The operative note—notation taken by the surgeon during a procedure to indicate precisely what was done, what was used, and what was ordered post-op.

Here are three quick tips for perfecting op notes in your facility.

Be Detailed & Maintain Proper Format

Start with the basics—make sure every op note includes standard information such as:

  • Patient Name
  • Surgeon Name
  • Applicable Pre-Operative Diagnostics
  • Changes to Planned Procedure

Indicate what was planned for the procedure and detail any changes that were made. If a procedure was made more or less intensive, cancelled midway through, or resulted in contradictory diagnosis with a need for further testing, include those specifics in the procedure line.

Literally every step taken (or planned steps that are not taken) should be reflected in the final op note.

Use Templates Appropriately

Countless facilities rely on templates for op notes, which is great; templates help ensure consistency and efficiency and provide prompts to gather all relevant details. But they’re not without inherent pitfalls.

The golden rule for template use is simply to update the language when necessary. Don’t assume the template is accurate for every procedure—avoid contradicting information by cross-referencing the template content with the surgeon’s notes and editing as necessary.

Remember, an op note is a legal document that can only be altered by a physician, so make every effort to ensure template reports are updated and augmented to accurately and consistently reflect the procedure as it was performed (not just as it was planned).

Be Consistent & Don’t Fear Repetition

If an op note says something once, most coders will assume that what was said is correct. If the same point is reiterated multiple times and in the exact same manner, the coder will trust that it’s an absolute fact. So don’t ever fear repetition. In fact, aim for it.

By extension, consider that every op note is a story, and the details need to be conveyed consistently and accurately for the story to make sense. Make certain that op note details are consistent with all other medical documentation and/or diagnoses, because a single contradicting element will absolutely stall the coding process.

The Long & Short of It

Taking a little extra time upfront to create clear and precise op notes can save considerable time on the backend. That means claims are processed quickly, patient collections are executed timely, and everyone (ideally) gets paid sooner.

Maybe you need a new pair of eyes to evaluate your op note templates. Or perhaps you’re wondering whether things could run more smoothly between your physicians and transcriptionists and coders. Stop wondering. Contact us and let in2itive Business Solutions evaluate your documentation processes and deliver the training and tips that could help you avoid hold-ups and denials.

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