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Op Report Coding Blog

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Z-plasty to the fingers

SURGICAL OP REPORT # 31

DIAGNOSIS:Second and third finger burn scar contracture.POSTOPERATIVE DIAGNOSIS: Same.

PROCEDURE:Z-plasty to the left second and third fingers, 6 cm for each z-plasty.

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Excision of burn area with split-thickness skin graft

SURGICAL OP REPORT # 30

DIAGNOSIS:Left arm third-degree burn.
OPERATION:Tangential excision of burn area with split-thickness skin grafting to left arm, sheet graft approximately 400 sq. cm.

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Atrial thrombectomy and Mitral valve ring annuloplasty , more

SURGICAL OP REPORT # 29

DIAGNOSIS: Congestive heart failure secondary to severe aortic valve stenosis, moderate mitral valve regurgitation, moderate tricuspid valve regurgitation, chronic atrial fibrillation, large atrial thrombus in left atrial appendage, small atrial thrombus in floor of left atrium.
PROCEDURE:1. Left atrial thrombectomy x2.2. Mitral valve ring annuloplasty for dilated mitral annulus utilizing a #30 Cosgrove partial ring.3. Cryo-MAZE procedure.4. Aortic valve replacement with a #25 bovine pericardial bioprosthesis.5. Tricuspid valve annuloplasty of the De Vega type.

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Closure of ventricular septal defect and Mitral valvuloplasty

SURGICAL OP REPORT # 28

DIAGNOSIS: Traumatic ventricular septal defect and traumatic mitral insufficiency.
OPERATION:1. Primary closure of ventricular septal defect.2. Mitral valvuloplasty.

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Exploratory thoracotomy and bX and multiple wedge resection

SURGICAL OP REPORT #27
DIAGNOSIS: Multiple pulmonary nodules.

PROCEDURE:Exploratory thoracotomy and biopsy and multiple wedge resection of right upper and lower lobes.

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