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The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.
The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx), physical examination (PE), consent ...
At some point before surgery a health care provider conducts a preoperative assessment to verify that a person is fit and ready for the surgery. [ 1 ] [ 2 ] For surgeries in which a person receives either general or local anesthesia, this assessment may be done either by a doctor or a nurse trained to do the assessment. [ 2 ]
The perioperative period is the period of a patient's surgical procedure. [1] It commonly includes ward admission, anesthesia, surgery, and recovery.Perioperative may refer to the three phases of surgery: preoperative, intraoperative, and postoperative, though it is a term most often used for the first and third of these only - a term which is often specifically utilized to imply 'around' the ...
Procedure codes are a sub-type of medical classification used to identify specific surgical, medical, or diagnostic interventions. The structure of the codes will depend on the classification; for example some use a numerical system, others alphanumeric.
Surgical planning is the preoperative method of pre-visualising a surgical intervention, in order to predefine the surgical steps and furthermore the bone segment navigation in the context of computer-assisted surgery. [1] The surgical planning is most important in neurosurgery and oral and maxillofacial surgery.
The circulating nurse is a perioperative nurse who assists in managing the nursing care of a patient during surgery. The circulating nurse observes for unintended breaches in surgical asepsis and coordinates the additional needs of the surgical team, such as procuring extra instruments, monitor operating room conditions, and liaising the ...
In the UK and Australia, surgical patients (those who have undergone a minor or major surgical procedure) are nursed on different wards from medical patients. Nursing practice on surgical wards differs from that of medical wards. Surgical nurses may practice in different types of surgery: General surgery (e.g. appendectomy, gallbladder removal)