American Academy of Professional Coders (AAPC) Practice Exam

Which of the following elements is typically found in the header of an operative report?

1. Patient's family history

2. Surgeon's credentials

3. Date and time of procedure

4. Insurance information

The correct answer is: Date and time of procedure

The correct selection is the date and time of the procedure, as this element is crucial in the context of an operative report. The header of an operative report is structured to provide essential details that establish the context and timing of the surgery performed. Documenting the date and time is vital for medical records to ensure accurate tracking of the patient's treatment timeline and for legal purposes, as it contributes to the integrity of the medical documentation. In contrast, while a patient's family history may be relevant elsewhere in the medical record, it is not typically included in the header of an operative report. Surgeon's credentials, although important, are generally documented in other sections or specific forms rather than the header. Insurance information is also not part of the operative report's header, as it pertains to billing and administrative aspects rather than the clinical details of the procedure. Thus, the inclusion of the date and time in the operative report header ensures the documentation meets medical standards and supports effective patient care continuity.