Question

Audit Report 5.2 Operative Report, Debridement

LOCATION: Inpatient, Hospital

PATIENT: Paul O'Reilly

SURGEON Mark Erickson, MD

PREOPERATIVE DIAGNOSIS: Multiple wounds of left leg and left thigh FOSTOPERATIVE DIAGNOSIS: Multiple wounds of left leg and left thigh (four wounds)

SURGICAL FINDINGS

1. 20 x 10 cm open wound of the medial aspect of the left leg that is clean. 2. 20 x 7 cm left lower leg lateral wound that is clean. 3. 24 x 11 left lateral thigh wound that is clean with exposed fascia. 4. 13 x 1.5 cm wound of the left anterior gangrenous fat within the wound.

PROCEDURE PERFORMED

1. Debridement of wound left anterior aspect, left thigh. 2. Split-thickness skin graft from the right thigh to the medial aspect of the left leg measuring 20 x 10 cm. 3.Split-thickness skin graft from the right lateral aspect of the lower left leg measuring 20 x 7 cm. 4. A split-thickness skin graft from the right thigh to the left lateral thigh measuring 24 x 11 cm. 5. Split-thickness skin graft from the right thigh to the left anterior thigh measuring 13 x 1.5 cm.

ESTIMATED BLOOD LOSS: Negligible.

ANESTHESIA: General endotracheal anesthesia

DESCRIPTION OF PROCEDURE The legs were prepped with Betadine scrub and solution, draped in a routine sterile fashion. The anterior left thigh wound was debrided and split-thickness skin grafts measuring 10,000th to 11,000th of an inch thick were taken from the right thigh, meshed with the 3:1 ratio mesher, and applied to all of the defects mentioned above of the left leg in the measurements noted. They were stapled to the wounds, mostly on the edges, and dressings then consisted of Xeroform, Kerlix fluffs, Kerlix roll, Kling and an Ace bandage. Estimated blood loss was negligible. Scarlet red was applied to the donor site. The patient tolerated the procedure well and left the area in good condition.

One of the codes is not reported for this case. Indicate the missing code.

PROFESSIONAL SERVICES Split-thickness graft to left thigh a left leg, 15100, 15101 X 6; Preparation of left anterior thigh for split thickness graft, 15002-51

ICD-10-CM DX: Open wound left leg. S81.802A; Open wound thigh, S71.102A.

MISSING CODE:

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