Question

Audit Report 5.4 Operative Report, Debridement

LOCATION: Inpatient, Hespital 

PATIENT: Arnie Holmes

PREOPERATIVE DIAGNOSIS: Right heel ulcer

POSTOPERATIVE DIAGNOSIS Right heel ulcer with Staphylococcus aureus infection

SURGEON: Gary Sanchez, MD

PROCEDURE PERFORMED: Debridement of right heel ulcer down to the bone

INDICATIONS FOR THIS PROCEDURE: Mr. Holmes is a 58-year-old male who has a large heel ulcer, measuring at least 7 cm x 3.5 cm in a curvilinear ovoid shape. This needs to be sharply debrided. There is a lot of necrotic tissue here. We need to see how deep this goes. We also need to obtain cultures. We need to determine for sure if he also has osten. If he does have other ongoing infection (this is reportable), this will require antitbiotic therapy. Cultures will be obtained of the deep tissues as well. The procedure and the risks were all discussed with the patient and his wife preoperatively. They understand, and their questions were answered. I also met with them in the preop holding room, and they had no new questions.

PROCEDURE: The more proximal aspect of this wound on the plantar aspect of the heel went deep, basically down to the bone. This was all sharply debrided back. We cleared some of the tissue overlying the bone there. The tissues were basically all necrotic down to there. We sent this off as a specimen. The remainder of the heel ulcer was not as deep. We sharply debrided the eschar off of it. We sharply debrided all of the edges of the wound. The tissues appeared to be viable there. I am somewhat concerned about how much deeper tissue of the foot and surroundings is necrotic. We appear to have some area of viability there. Hemostasis was achieved. We washed it out with a liter of antibiotic solution of Bactar and Kanamycin using an Ortholav system. The wound was packed open with wet-to-dry dressings. The patient tolerated the procedure well.

Pathology Report Later Indicated: Staphylococcus aureus

One or more of the following codes are reported incorrectly for this case. Indicate the incorrect code or codes

SERVICE CODEISE Bone debridement, 11044, 11047

ICD-10-CM DX CODE(S). Pressure ulcer with muscle necrosis heel, L97.413

INCORRECT/MISSING CODE(S);

$PXL_20210327_194646301~3.jpg$

$PXL_20210327_194716644~3.jpg$

$PXL_20210327_195012701~3.jpg$

$PXL_20210327_195023398~3.jpg$

$PXL_20210327_195034261~3.jpg$

$PXL_20210327_195043691~3.jpg$

$PXL_20210327_195101319~3.jpg$