American Academy of Professional Coders (AAPC) Practice Exam

What type of details may be included in the operative report's header?

1. Post-operative recovery plan

2. Total charge for the procedure

3. Name of the anesthesiology provider

4. Patient's allergies

The correct answer is: Name of the anesthesiology provider

The header of an operative report typically includes essential identifying information regarding the procedure and the individuals involved. The inclusion of the name of the anesthesiology provider is crucial for several reasons. First, it indicates who was responsible for the anesthesia care during the surgical procedure. This is important not only for medical record-keeping but also for accountability and safety, ensuring that the appropriate anesthesiologist can be identified should any issues arise during or after the surgery. In contrast, the post-operative recovery plan, total charge for the procedure, and the patient's allergies, while important aspects of patient care and documentation, are generally not part of the operative report's header. The recovery plan is often contained in different sections of a patient's medical record, the total charge is a financial aspect not typically highlighted in operative reports, and patient allergies are usually documented in the medical history rather than the operative report’s header.