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I Have A Question About Operative Report Using INPATIENT Hospital
I have a question about operative report using INPATIENT hospital guidelines to those who is familiar with this scenario.
PRE/POSTOPERATIVE DIAGNOSIS: Postmenopausal bleeding with probable polyp seen on saline sonohysterogram.
OPERATIVE FINDINGS: Endometrial polyp seen arising from the left cornual region. Otherwise, benign uterine cavity.
PROCDEDURE: The patient was taken to the operation room and general anesthesia was administered. The patient was then prepped and draped in the usual manner in lithotomy postion and the bladder was emptied with straight catheter. A weighted speculum was placed to allow for visualization of the cervix, which was grasped anteriorly using single-toothed tenaculum. The uterus was then sounded to 9cm depth. The cervix was dilated to allow for insertion of the diagnostic hysteroscope. The uterine cavity was then inspected. Immediately apparent was a polyp arising from the left cornual region. Remainder of the uterine cavity was inspected and apppered to be benign. Minimal endometrial tissue was otherwise present.
At this point, the hysteroscope was removed, and polyp forces was place within the uterus. Attempt was made to grasp the polyp, but this could not be grabbed with polyp forceps. Therefore, a sharp curet was used and the polyp was thereby obtained and removed. A small amount of endometrial tissue was also obtained by curettage. Once this had been completed, the hysteroscope was reinserted and the cavity was reinspected. It was confirmed that the polyp was removed. Otherwise, the endometrial canal then appeared normal. At this point, the procedure was terminated. Tenaculum was removed, and good hemostasis was ensured at the cervix. The patient tolerated this procedure well. There were no complications. Fluid in was 325 cc and was equal to fluid out at the end of the procedure. Estimated blood was minimal. Please provide CPT Code:_______ and ICD-9-CM Code:_______
PRE/POSTOPERATIVE DIAGNOSIS: Postmenopausal bleeding with probable polyp seen on saline sonohysterogram.
OPERATIVE FINDINGS: Endometrial polyp seen arising from the left cornual region. Otherwise, benign uterine cavity.
PROCDEDURE: The patient was taken to the operation room and general anesthesia was administered. The patient was then prepped and draped in the usual manner in lithotomy postion and the bladder was emptied with straight catheter. A weighted speculum was placed to allow for visualization of the cervix, which was grasped anteriorly using single-toothed tenaculum. The uterus was then sounded to 9cm depth. The cervix was dilated to allow for insertion of the diagnostic hysteroscope. The uterine cavity was then inspected. Immediately apparent was a polyp arising from the left cornual region. Remainder of the uterine cavity was inspected and apppered to be benign. Minimal endometrial tissue was otherwise present.
At this point, the hysteroscope was removed, and polyp forces was place within the uterus. Attempt was made to grasp the polyp, but this could not be grabbed with polyp forceps. Therefore, a sharp curet was used and the polyp was thereby obtained and removed. A small amount of endometrial tissue was also obtained by curettage. Once this had been completed, the hysteroscope was reinserted and the cavity was reinspected. It was confirmed that the polyp was removed. Otherwise, the endometrial canal then appeared normal. At this point, the procedure was terminated. Tenaculum was removed, and good hemostasis was ensured at the cervix. The patient tolerated this procedure well. There were no complications. Fluid in was 325 cc and was equal to fluid out at the end of the procedure. Estimated blood was minimal. Please provide CPT Code:_______ and ICD-9-CM Code:_______
