HCPCS Procedure G9304 Operative Report

Name of the Procedure:

Prosthetic Implant Specification Documentation

Summary:

This medical procedure involves documenting the specifications of prosthetic implants used during surgery. It details the prosthetic implant manufacturer, the brand name, and the size of each prosthetic implant utilized.

Purpose:

The primary purpose of this documentation is to ensure accurate records for future reference regarding the prosthetic implants used, aiding in patient care continuity, and verifying the suitability and performance of specific implants.

Indications:

• Patients undergoing joint replacement or reconstructive surgery.
• Situations where the selection and fit of a prosthetic implant are critical for successful surgical outcomes.
• Cases requiring detailed records for follow-up treatments or potential revision surgeries.

Preparation:

• Pre-surgical consultations and assessments.
• Diagnostic imaging (e.g., X-rays, MRIs) to determine appropriate implant size and type.
• Patient briefing on the procedure, including fasting and medication instructions.

Procedure Description:

1. Pre-operative Phase: Conduct thorough pre-operative assessments and imaging studies.
2. Surgical Phase:
   • Administer anesthesia or sedation as necessary.
   • Perform the surgical procedure involving the implantation of the prosthetic.
   • Measure and record the specifications of the implanted prosthetics, including manufacturer, brand, and size.
3. Post-operative Phase: Document all details in the patient's medical records for future reference.

Duration:

Documentation of the prosthetic specifications typically takes a few minutes at the conclusion of the implantation procedure.

Setting:

This documentation takes place in the surgical suite, within hospitals or outpatient surgical centers.

Personnel:

• Orthopedic Surgeon
• Surgical Assistant
• Nurse
• Anesthesiologist (if sedation is used)
• Medical Recorder

Risks and Complications:

Since this is a documentation step, there are minimal direct risks associated with the procedure itself. However, ensuring accurate documentation is crucial to mitigate risks related to implant failure, incompatible revisions, or post-surgical complications.

Benefits:

Maintains a reliable and accessible record of the prosthetic implants used, facilitating:

• Better post-operative care and follow-up.
• Improved management of potential complications.
• Consistency in patient medical records.

Recovery:

As this is a record-keeping procedure, no additional recovery is required beyond the standard surgical recovery process.

Alternatives:

Documentation alternative methods may include manual entries in physical patient records or utilizing digital health records systems. The goal remains the same: ensuring accurate and comprehensive implant records.

Patient Experience:

Patients typically will not notice this specific documentation step as it occurs during or immediately after the surgical procedure. Pain management and comfort measures will be part of the overall surgical care plan.