American Academy of Professional Coders (AAPC) Practice Exam

What detail is NOT likely included in the header of an operative report?

1. Type of anesthesia used

2. Name of the patient

3. Pre-operative and post-operative diagnoses

4. Follow-up care instructions

The correct answer is: Follow-up care instructions

The detail that is typically not included in the header of an operative report is the follow-up care instructions. Operative reports generally focus on documenting the specifics of the procedure itself, such as the type of anesthesia used, the name of the patient, and both pre-operative and post-operative diagnoses. The header serves to identify essential patient and procedure details that are critical for immediate reference and understanding of the operation. Follow-up care instructions, while vital for patient management and recovery, are usually detailed in the body of the report rather than the header. This distinction highlights the purpose of the header as a quick reference point for information directly related to the surgical process, while follow-up care is more applied to post-surgery patient management.