Sample Chart 1
Reason For Exam
cancer;Other
Report
PROCEDURE: PICC PLACEMENT USING ULTRASOUND AND FLUOROSCOPIC-GUIDANCE:
CLINICAL INFORMATION: Malignant neoplasm of tonsil.
FINDINGS: This central venous catheter was inserted with all elements of maximal sterile barrier technique, cap and mass and sterile gown and sterile gloves and sterile full body drape and hand hygiene and 2% chlorhexidine for cutaneous antisepsis. Sterile ultrasound technique with sterile gel and sterile probe cover utilized.
A right arm 5 French PICC was placed in standard fashion in the right brachial vein using direct ultrasound and fluoroscopic guidance. An ultrasound image was obtained and stored in PACS. Final tip location is in the mid superior vena cava.
Fluoroscopy time: 6 seconds.
Images: 1.
Images were captured from the real-time fluoroscopy but no conventional fluoroscopic image was obtained.
IMPRESSION:
TECHNICALLY SUCCESSFUL PLACEMENT OF A RIGHT ARM PICC.
36573 – Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, including all imaging guidance, image documentation, and all associated radiological supervision and interpretation required to perform the insertion; age 5 years or older
C09.9 –
Sample Chart 2
COLONOSCOPY REPORT
LOCATION: Cedar Lake Surgery Center
COLONOSCOPY: Diagnostic
LAST COLONOSCOPY: None
INDICATIONS: Change in bowel pattern, left-sided abdominal pain
MEDICATIONS: See anesthesia note
DESCRIPTION: The Colonoscopy was explained in detail to the patient prior to the procedure including risks such as bleeding and colonic perforation. The patient was informed that in the event of a complication, they may require surgery to treat the complication. The patient was brought to the endoscopy suite and placed in the left lateral decubitus position. On external anal exam, there was no evidence of external hemorrhoids or fissures. On digital rectal exam there was no palpable masses. A standard Olympus colonoscope was inserted into the rectum and passed in the usual fashion to the level of the terminal ileum. The preparation of the colon was excellent with a Boston bowel prep score of 9. The scope was then slowly withdrawn and careful examination of the entire colon was performed.
FINDINGS / THERAPY:
Ileum -normal
Cecum -normal
Ascending colon -normal
Hepatic flexure -normal
Transverse colon -normal
Splenic flexure -normal
Descending colon -normal
Sigmoid colon -patient has a lot of spasm in the sigmoid colon but there is no evidence of colitis or neoplastic disease
Rectum -normal
Anal canal -normal
***Withdrawal time 8 minutes
IMPRESSION:
1. Normal colonoscopy
2. IBS
45378 – Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
R109
R194
Sample Chart 3
Indication for Surgery: right small finger proximal phalanx fracture, comminuted, displaced
Preoperative Diagnosis: right small finger proximal phalanx fracture, comminuted, displaced
Postoperative Diagnosis: Same as above
Operation:
1-right small finger proximal phalanx fracture, open reduction internal fixation
Anesthesia:
Gen.
Estimated Blood Loss:
Minimal
Urine Output:
NA
Findings:
Consistent with diagnosis
Specimen(s):
none
Complications:
None
Technique:
Description of procedure in detail; the right upper extremity was prepped and draped in standard sterile fashion. Surgical timeout was performed prior to initiation of procedure utilizing two patient identifiers. The extremity was exsanguinated with an Esmarch, tourniquet utilized at 250 mmHg, see chart for total tourniquet time. Attention was then turned to the right small finger, incision made with a 15 blade scapel over the proximal phalanx. Blunt dissection to the digital neurovascular structures was performed with Stevens tenotomy scissors, the digital artery and nerve were then protected throughout the remainder of the case. Attention was then turned to the subperiosteal dissection, the fracture was then visualized and taken down with 15 blade scalpel and freer elevator. Periosteal exposure was performed until the 3 comminuted fragments of the fracture were well visualized the distal to fracture fragments were then reduced provisionally with a 0.045 Kirschner wire and reduction forceps. Two 1.5 millimeter screws were then placed and evaluated under direct fluoroscopy visualization and found to have near anatomic alignment of the distal fracture fragment. Attention was then turned to the proximal fracture fragment this was reduced to the 2 distal fragments in a similar fashion utilizing reduction forceps and a provisional 0.045 Kirschner wire. 2 screws were then placed perpendicular to the major fracture line 1.5 millimeter screws. At the completion of this the 2 Kirschner wires were removed. Fracture reduction was assessed under AP and lateral fluoroscopic imaging. There was near anatomic alignment of the fracture. Periosteum was then closed utilizing 4-0 Vicryl with a P3 needle in a running fashion. The extensor tendon was then closed in a similar fashion. The wound was copiously irrigated tourniquet was let down prior to closure hemostasis obtained skin closed with 4-0 Monocryl suture. A ulnar gutter splint with the metacarpal phalangeal flexed at 60 degrees was then applied. There were no complications. The sponge instrument and needle count were verified and correct x2.
Disposition-
Patient will initiate hand therapy within the next 7 days return to the office 2 weeks for wound check sooner as needed.
26735-RT Open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, includes internal fixation, when performed, each
S62616A Displaced fracture of proximal phalanx of right little finger, initial encounter for closed fracture
Sample Chart 4
Preoperative Diagnosis: [Multilevel cervical degenerative disc disease, upper extremity radiculopathy, neck pain, cervicalgia, chronic pain syndrome]
Postoperative Diagnosis: Same
Procedure: Cervical epidural steroid injection, level C6-7 via midline approach, with fluoroscopy and epidurogram
Anesthesia: Local anesthesia with I.V. sedation per Department of Anesthesia due to complications associated with anxiety and low pain threshold due to complications associated with severe chronic pain.
Complications: None
Procedure Note: The risks and benefits of the procedure were discussed with the patient prior to having them sign an informed consent. The patient’s vital signs were obtained and found to be satisfactory. The patient was subsequently therefore taken to the operative suite. Once in the operative suite the patient was placed in the prone position. After adequate sedation was obtained, the neck area was cleansed in the standard fashion with Betadine solution. Appropriate sterile drapes were placed. The skin and deep tissues at the level of C6-7 via fluoroscopy guidance were anesthetized with 1% Xylocaine solution. Subsequently, a 18-gauge 3½ inch Tuohy epidural needle was advanced via midline approach until the cervical epidural space was identified. There was no heme, CSF, or paresthesia appreciable. At this point an epidurogram was performed with 1 cc of Isovue solution with the tip of the needle midline between C6-7. Confirmation of needle placement was made. An epidurogram was performed which showed excellent spread of the Contrast solution one segment above and one segment below the tip of needle placement. Hard copy film was obtained. Subsequently, therefore, 120 mg of Depo-Medrol and 4 cc of Preservative-Free normal saline were injected into the cervical epidural space without complications. The needle was removed. The back was cleansed and a Band-Aid was placed over the puncture site.
62321 – Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)
M50123 Cervical disc disorder at C6-C7 level with radiculopathy
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