anwalden
Guest
I'm hoping I could get some secondary opinions on this Op Note. I'm wavering on coding the arthrotomy. The physician states that there was already a hole into the joint from the laceration that he opened up. What would you do?
OPERATIVE NOTE
PREOPERATIVE DIAGNOSIS: Open knee laceration.
POSTOPERATIVE DIAGNOSIS: Open knee laceration.
PROCEDURE: Irrigation and debridement of intra-articular knee laceration with closure over drain.
ANESTHESIA: General.
INDICATIONS AND CONSENT: _______ is a 40-year-old who caught his leg with his chainsaw. When he did that he had evaluation at ______where he was found to have deep multiple lacerations and by x-ray, air inside his knee. I had discussed with him what options we had after he was referred down to my office for treatment and we elected to bring him emergently to the surgery center for irrigation and debridement. We talked about what options he had and because of his financial situation he strongly desired to utilize the surgery center instead of the hospital. He understood issues relative to the surgery center with financing and he gave his consent to proceed.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room where the timeout was done. Person, place, allergies, and antibiotics were all confirmed. He was placed on the operating room table. The leg was prepped and draped in standard fashion. We did inflate the tourniquet. We took the horribly avulsed skin margins and sharply cleaned up the edges. The deep tissue was sharply cleaned up until it was all smooth and viable. On the proximal of the two 8-cm lacerations, I explored it. I found the hole into the joint. The hole itself was a 3-mm laceration. I opened it up. I was able to adequately irrigate the entire joint. I did that with 3000 cc of saline. After irrigation, I placed a Penrose drain that ran underneath an intact skin bridge and with that accomplished, I closed the proximal laceration. I then went and placed a second Penrose drain which laid on top of the more widely opened distal laceration. I used 3-0 Vicryl to approximate the subcutaneous tissue on both proximal and distal and closed it with staples. A sterile dressing was applied. After the tourniquet was let down, hemostasis was controlled. I did inject the knee with 30 cc of Marcaine/Xylocaine with epinephrine. There were no complications to the procedure.
OPERATIVE NOTE
PREOPERATIVE DIAGNOSIS: Open knee laceration.
POSTOPERATIVE DIAGNOSIS: Open knee laceration.
PROCEDURE: Irrigation and debridement of intra-articular knee laceration with closure over drain.
ANESTHESIA: General.
INDICATIONS AND CONSENT: _______ is a 40-year-old who caught his leg with his chainsaw. When he did that he had evaluation at ______where he was found to have deep multiple lacerations and by x-ray, air inside his knee. I had discussed with him what options we had after he was referred down to my office for treatment and we elected to bring him emergently to the surgery center for irrigation and debridement. We talked about what options he had and because of his financial situation he strongly desired to utilize the surgery center instead of the hospital. He understood issues relative to the surgery center with financing and he gave his consent to proceed.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room where the timeout was done. Person, place, allergies, and antibiotics were all confirmed. He was placed on the operating room table. The leg was prepped and draped in standard fashion. We did inflate the tourniquet. We took the horribly avulsed skin margins and sharply cleaned up the edges. The deep tissue was sharply cleaned up until it was all smooth and viable. On the proximal of the two 8-cm lacerations, I explored it. I found the hole into the joint. The hole itself was a 3-mm laceration. I opened it up. I was able to adequately irrigate the entire joint. I did that with 3000 cc of saline. After irrigation, I placed a Penrose drain that ran underneath an intact skin bridge and with that accomplished, I closed the proximal laceration. I then went and placed a second Penrose drain which laid on top of the more widely opened distal laceration. I used 3-0 Vicryl to approximate the subcutaneous tissue on both proximal and distal and closed it with staples. A sterile dressing was applied. After the tourniquet was let down, hemostasis was controlled. I did inject the knee with 30 cc of Marcaine/Xylocaine with epinephrine. There were no complications to the procedure.