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The Patient Is Brought Back to the Operating Room for a Staged

Question 52

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The patient is brought back to the operating room for a staged procedure to a procedure that was performed 5 days previously.
LOCATION: Inpatient, Hospital
PATIENT: Soren Gademore
SURGEON: Gary Sanchez, M.D.
DIAGNOSIS: Status post open wound, right lower extremity.
SURGICAL PROCEDURE: Split thickness skin graft, right thigh to right lower extremity.
DESCRIPTION OF PROCEDURE: The patient's right leg was prepped with Betadine scrub and solution and draped in the routine sterile fashion. A skin graft was taken from the right thigh on its anterolateral aspect, meshed with a 1:1.5 ratio mesher, and applied to the 66 sq cm defect on the right leg with staples. Dressing consisted of Xeroform, Kerlix fluffs, Kerlix roll, Kling, Sof-Rol, and a short leg fiberglass cast. Scarlet Red and ABD pads were applied to the donor site. The patient tolerated the procedure well and left the area in good condition.
Pathology Report Later Indicated: Benign tissue
CPT Code: ____________________

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