Operative Note Library
Last reviewed: June 2026
The Operative Note Library teaches documentation by contrast: weak examples, stronger examples, and the coding implications that follow.
Laparoscopic Cholecystectomy
Poor Documentation Example
"Laparoscopic Cholecystectomy performed. Patient tolerated procedure well."
This is weak because it does not explain indication, operative findings, critical steps, complexity, complications, specimens, implants, anatomic details, or whether separately reportable work was performed.
Strong Documentation Example
"After informed consent, the patient was taken to the operating room for laparoscopic cholecystectomy. The indication, key findings, approach, critical steps, and completion of the operation were documented. Relevant anatomy, complexity, and complications were addressed, and the patient left the operating room in stable condition."
Coding Implications
Coders and reviewers need the operative note to support the CPT family, approach, global period, modifier use, medical necessity, and whether additional services were actually distinct.
Open Inguinal Hernia Repair
Poor Documentation Example
"Open Inguinal Hernia Repair performed. Patient tolerated procedure well."
This is weak because it does not explain indication, operative findings, critical steps, complexity, complications, specimens, implants, anatomic details, or whether separately reportable work was performed.
Strong Documentation Example
"After informed consent, the patient was taken to the operating room for open inguinal hernia repair. The indication, key findings, approach, critical steps, and completion of the operation were documented. Relevant anatomy, complexity, and complications were addressed, and the patient left the operating room in stable condition."
Coding Implications
Coders and reviewers need the operative note to support the CPT family, approach, global period, modifier use, medical necessity, and whether additional services were actually distinct.
Robotic Ventral Hernia Repair
Poor Documentation Example
"Robotic Ventral Hernia Repair performed. Patient tolerated procedure well."
This is weak because it does not explain indication, operative findings, critical steps, complexity, complications, specimens, implants, anatomic details, or whether separately reportable work was performed.
Strong Documentation Example
"After informed consent, the patient was taken to the operating room for robotic ventral hernia repair. The indication, key findings, approach, critical steps, and completion of the operation were documented. Relevant anatomy, complexity, and complications were addressed, and the patient left the operating room in stable condition."
Coding Implications
Coders and reviewers need the operative note to support the CPT family, approach, global period, modifier use, medical necessity, and whether additional services were actually distinct.
Thyroidectomy
Poor Documentation Example
"Thyroidectomy performed. Patient tolerated procedure well."
This is weak because it does not explain indication, operative findings, critical steps, complexity, complications, specimens, implants, anatomic details, or whether separately reportable work was performed.
Strong Documentation Example
"After informed consent, the patient was taken to the operating room for thyroidectomy. The indication, key findings, approach, critical steps, and completion of the operation were documented. Relevant anatomy, complexity, and complications were addressed, and the patient left the operating room in stable condition."
Coding Implications
Coders and reviewers need the operative note to support the CPT family, approach, global period, modifier use, medical necessity, and whether additional services were actually distinct.
Colectomy
Poor Documentation Example
"Colectomy performed. Patient tolerated procedure well."
This is weak because it does not explain indication, operative findings, critical steps, complexity, complications, specimens, implants, anatomic details, or whether separately reportable work was performed.
Strong Documentation Example
"After informed consent, the patient was taken to the operating room for colectomy. The indication, key findings, approach, critical steps, and completion of the operation were documented. Relevant anatomy, complexity, and complications were addressed, and the patient left the operating room in stable condition."
Coding Implications
Coders and reviewers need the operative note to support the CPT family, approach, global period, modifier use, medical necessity, and whether additional services were actually distinct.
Source and Verification References
Use this page as educational coding support, then verify final coding decisions against current official and payer-specific guidance.