Sample Surgery Medical report for Medical coders

Sample Interventional Vascular Coding Practice charts

PREOPERATIVE DIAGNOSES: Rule out rotator cuff tear of the right shoulder.

POSTOPERATIVE DIAGNOSES: 1. Partial thickness tear of supraspinatus, right shoulder.

  1. Type II superior labral tear, right shoulder.

  2. Degenerative joint disease with chondral injury and multiple loose bodies intraarticularly, right shoulder.

OPERATIVE PROCEDURES:

ANESTHESIA: General endotracheal.

ESTIMATED BLOOD LOSS: Minimal.

Sample Surgery Medical report for Medical coders

DESCRIPTION OF PROCEDURE:

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