American Academy of Professional Coders (AAPC) Practice Exam

What is the purpose of an operative report?

1. To summarize patient complaints

2. To document the details of a procedure performed on a patient

3. To provide billing information

4. To record patient personal history

The correct answer is: To document the details of a procedure performed on a patient

An operative report serves a crucial role in the medical field by documenting the intricate details of a procedure performed on a patient. This report is created by the surgeon or the healthcare provider who performed the operation and includes essential information such as the type of procedure, the techniques employed, the findings during surgery, and any complications that arose. It provides a comprehensive record that not only serves as a legal document but also is vital for continuity of care, allowing other healthcare providers to understand what was done during the procedure and any follow-up necessary. While the other choices touch on aspects of patient care and documentation, they do not capture the specific and detailed nature of an operative report. Summarizing patient complaints or providing billing information does not encompass the surgical details needed to convey the complete scope of the operative intervention. Similarly, recording patient personal history is separate from the specific procedural information that the operative report is intended to encapsulate. The primary function of the operative report is to ensure thorough documentation of the procedure itself, making it a vital component of medical records.