AUDIT REPORT T8.1 OPERATIVE REPORT, CLOSEDREDUCTION
| LOCATION: |
Outpatient, Hospital |
| PATIENT: |
Kelli Klarkor |
| SURGEON: |
Mohomad Almaz, MD |
| DIAGNOSIS: |
Displaced fractured base, left first metacarpal |
| PROCEDURE PERFORMED: |
Closed reduction of metacarpal fracture |
INDICATION: Kelli is a 15-year-old girl who fell while rollerblading. She has now fractured her left thumb and will needmanipulation to put it back in place. I have recommended a closedreduction and thumb spica cast application. The mother agrees withthis.
PROCEDURE: Under a satisfactory level of sedation, the fracture wascarefully manipulated and a well-padded and very well-moldedfiberglass cast was placed over the base of the thumb. After thiswas applied, we applied repeat mini C-arm views and confirmedimprovement in position of the fracture but still not in anatomicposition.
Where it is presently, if it heals, it still will be completelyfunctional. I reviewed this with the mother, and I have recommendedthat we cast this and re-manipulate it as the swelling goes down,and we will do this sometime next week.
T8.1:
SERVICE CODE(S): 26607-FA___________
ICD-10-CM DX CODE(S): S62.399A________
INCORRECT/MISSING CODE(S):________________________________________
