American Academy of Professional Coders (AAPC) Practice Exam

What is a common section found in the body of an operative report?

1. Medication prescriptions

2. Procedures performed

3. Patient's vital signs

4. Referral details

The correct answer is: Procedures performed

The body of an operative report typically includes a comprehensive description of the procedures performed during the surgery. This section details the specific surgical techniques used, the findings during the operation, and any relevant observations made by the surgeon. Including this information is essential for documenting the surgical process and communicating effectively with other healthcare professionals who may review the report later. While aspects such as medication prescriptions, vital signs, and referral details may be part of a patient's overall medical documentation or pre-operative and post-operative notes, they are not generally included in the operative report's main body. The focus of an operative report is on the surgical procedure itself, making the documentation of procedures performed crucial for maintaining accurate and complete surgical records.