HIM 205 CHART AUDITING AUDIT REPORT T10.1

HIM 205 CHART AUDITING AUDIT REPORT T10.1 OPERATIVE REPORT, RESECTION LOCATION: Outpatient, Hospital PATIENT: Donald Styel SURGEON: Ira Avila, MD PREOPERATIVE DIAGNOSIS: Left hydrocele, left scrotal mass PATIENT: Left hydrocele PROCEDURE PERFORMED: Resection of hydrocele sac, left testicular cord, left scrotum, and resection of left paratesticular mass. CLINICAL NOTE: This is a 78-year-old gentleman who has developed a hydrocele and has a left scrotal mass. We have discussed different options, and he has decided he would like this surgically taken care of. The patient has been marked earlier for surgery. OPERATIVE NOTE: The patient was given a general endotracheal anesthetic, prepped, and draped in the supine position. A midline scrotal incision was made and the testis delivered. Two hydroceles were identified, one of the testis and one of the cord. The hydrocele of the cord was resected. Hemostasis was achieved with electrocautery. The hydrocele sac of the scrotum was also opened and resected. Once opening this, there was a very dark 1.5-cm lesion separate from the epididymis and testis in the region of the testicular cord. This was mobilized, isolated, and resected intact. It did not appear to have a blood supply or be in association with any of the cord or testicular structures. This was sent separately for pathologic identification. Once hemostasis was achieved, the testis was returned to the scrotum. A 1/4-inch Penrose drain was left through a separate stab wound and sutured to the skin with 2-0 Prolene. The scrotum was closed in two layers with a 3-0 chromic. Dressings applied. Scrotal support applied. The patient was transferred to the recovery room in good condition. 10.1: SERVICE CODE(S): 55040, 55500-51 ICD-10-CM DX CODE(S): N43.3, N50.9 INCORRECT/MISSING CODE(S):_________________________ T11-1A OBSTETRICAL ULTRASOUND LOCATION: Inpatient, Hospital PATIENT: Patricia Garrison ATTENDING PHYSICIAN: AndyMartinez, MD RADIOLOGIST: Morton Monson, MD EXAMINATION OF: Limited OB (obstetrics) ultrasound CLINICAL SYMPTOMS: Twin gestation of vertex/breech at 36 weeks; please check position LIMITED OB ULTRASOUND: FINDINGS: A twin gestation is identified. Twin A lies to maternal right and is in longitudinal lie and breech presentation according to technologist’s sheet. Twin B lies to maternal left and is in longitudinal lie in cephalic presentation. Twin B appears to be the presenting twin. Fetal heart rate for baby A is 148 beats per minute, and for baby B, 154 beats per minute. No further evaluation was performed on today’s exam. T11-1A: SERVICE CODE(S):___________________ ICD-10-CM DX CODE(S):_______________ SCIENCE HEALTH SCIENCE

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