Lymph Node Chains, Omentectomy and CABG Clinical Documentation

Lymph Node Chains

                                  Lymph Node Chains

 

• Document extent of excision/resection:
    --Entire lymph node chain
    --Portion of lymph node chain
• Document site:
    --Head
    --Right/Left neck
    --Right/Left upper extremity
    --Right/Left axillary
    --Thorax
    --Right/Left internal mammary
    --Mesenteric
    --Pelvis
    --Aortic
    --Right/Left lower extremity
    --Right/Left inguinal

Omentectomy

• Document the body part being resected/excised:
    --Greater omentum
    --Lesser omentum

Lysis of Adhesions

• Document the body part being released/freed, examples:
    --Jejunum
    --Ascending Colon
    --Gallbladder
    --Peritoneum
    --Document the severity of adhesions, such as, complicated,
extensive, etc.

Cleft Palate Repair

• Specify the following:
    --Palate description Hard/Soft/Both
    --Bilateral/Unilateral
    --Complete/Incomplete
    --With/without Cleft Lip Involvement
    --If Cleft Lip involvement—Bilateral/Unilateral

CABG

• Origination/Destination of graft(s)
    --Examples: aorta to RCA, LIMA to LAD (indicate if the LIMA was
used as a pedicle graft)
• Type of graft(s) used
    --Examples: autologous artery, autologous vein, etc.
• Number of sites bypassed
    --Examples: one, two, three, or four, or more
• Excision of autologous graft
    --Identify the vessel
       °°Examples: greater/lesser saphenous vein (left/right), radial artery
(left/right)