AAMA CMA Practice Question

An operative note is a detailed document that describes the surgery performed on a patient. It includes information about the preoperative diagnosis, the postoperative diagnosis, the procedure performed, and any specimens removed. This document is crucial for providing a comprehensive view of the surgery, ensuring continuity of care, and supporting accurate billing and coding. It is a legal document that must be included in the patient's medical record. An operative note does not primarily schedule the surgery or provide a general medical history, as these elements are covered in other documents.