Transcription of Documentation Dissection - AAPC
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Documentation Dissection - AAPC
1 Documentation DissectionCRNA provided anesthesia and prior to start of anesthesia inserted a CVP and TIME: 7:02 to 9:46 EOPER ATIV E DIAGNOSIS:1. Severe multivessel coronary artery occlusive disease with increasing Non-Q wave myocardial Non-insulin dependent diabetes DIAGNOSIS:1. Severe multivessel coronary artery occlusive disease with increasing Non-Q wave myocardial Non-insulin dependent diabetes OF PROCEDURE: Coronary artery bypass graft times three (left internal mammary artery to mid LAD, saphenous vein graft to intermediate and saphenous vein graft to distal right coronary artery).ANESTHESIA: General ISTORY: This patient is a 67-year-old female with known coronary artery occlusive disease treated medically. She has had increasing angina. She has multiple risk factors. Repeat catheterization showed rather significant progression of disease with non-Q wave MI and recommendation was made for bypass grafting. Ventricular function was well-preserved and was OF OPERATIVE PROCEDURE: The patient was brought to the operating room.
2 sternum was closed with multiple interrupted wire, linea alba with #1 Tevdek, presternal fascia with -0- Dexon, the skin with 4-0 subcuticular Dexon and Dermabond.
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