Surgery Practice Note:
Patient Name: John Doe
DOB: 01/01/1960
Date of Service: 05/01/2020
Procedure: Laparoscopic Cholecystectomy
Preoperative Diagnosis: Cholecystitis
Postoperative Diagnosis: Cholecystitis
Procedure Description: The patient was brought to the operating room and placed under general anesthesia. The abdomen was prepped and draped in the usual sterile manner. A Veress needle was inserted into the umbilicus, and pneumoperitoneum was established. A 10 mm trocar was inserted through the umbilicus, and the laparoscope was introduced. Additional 5 mm trocars were inserted in the right upper quadrant and epigastric region. The dissection was carried down to the gallbladder, which was identified and dissected free from the liver bed. The cystic artery and duct were ligated and divided. The gallbladder was removed through the umbilical port. The ports were removed, and the incisions were closed in layers. The patient tolerated the procedure well and was taken to the recovery room in stable condition.
Anesthesia: General anesthesia
Surgeon: Dr. John Smith
Assistant: Dr. Jane Doe
Blood loss: Minimal
Specimen sent to pathology: Gallbladder
Complications: None
Follow-up: The patient was seen in the office two weeks after surgery and was doing well. He reported no pain or other symptoms. The incisions were healing well, and the patient was instructed to resume normal activities.
Please note that this is a general example, and the information in a real-world medical chart may vary depending on the procedure and the individual patient’s case. Additionally, medical coders should follow the official coding guidelines and use the appropriate codes based on the documentation provided by the healthcare provider.