American Academy of Professional Coders (AAPC) Practice Exam

Which component is essential in a well-written operative report?

1. Social history

2. Header and Body

3. Physical examination

4. Patient demographic information

The correct answer is: Header and Body

A well-written operative report must include the header and body as essential components. The header typically contains crucial patient information such as the patient’s name, medical record number, date, and type of surgery. This establishes the context and pertinent details surrounding the surgery. The body of the report outlines the specifics of the procedure, including the indications for surgery, surgical technique, findings, and any complications encountered. This section provides a comprehensive and detailed narrative that is essential for the operative report to serve its purpose in the medical record. Other components, such as social history, physical examination, and patient demographic information, while important in the overall medical documentation, are not specific to the operative report itself. The focus here is clearly on the structural components that convey the critical information necessary for understanding the procedure performed.