A finished HIM-355 Topic 2 operative report abstraction example, breaking one composite operative report into actions and recording body part, objective, approach and device for each. Searches like "him 355 topic 2 assignment example", "him355 topic 2 sample" and "him-355 topic 2 example" land here.
What a finished HIM-355 Topic 2 operative report abstraction looks like
The finished abstraction is the report and a grid, set side by side. The composite report has the usual parts: pre- and postoperative diagnoses, the procedure title, indications, findings, a narrative description, specimens, estimated blood loss and complications. The grid sets the headings aside and works from the narrative, giving each distinct action its own row with the body part, the objective of the action in the surgeon's words, the approach, any device that remains at the end, and the specimen if one went to pathology. In this composite case a loop of small bowel bound down by adhesions is freed and nothing is removed, so the grid records the bowel as the body part released rather than the adhesions that were cut. Exploration done to reach that objective is marked as integral, not given a row.
How an HIM-355 Topic 2 example is structured
The abstraction moves from the report's surface to its substance. It begins with the composite report reproduced in full, so each grid row has a sentence it came from. The headings are then read briefly and put aside, with a note on which ones matter later, such as specimens and devices. The narrative is next divided into actions, each bounded by what the surgeon did rather than by paragraph breaks. For every action the grid records five things: body part, objective, approach, device remaining and specimen. A reconciliation passage follows, comparing the grid with the procedure title and listing each disagreement between them. A final passage lists what the narrative leaves open, such as which segment of bowel was involved, and drafts the neutral question to the surgeon that would settle it.
The report reproduced before the grid
Every row in the abstraction points back to a sentence in the composite report, which appears in full so the tracing can be checked line by line.
Narrative divided by action, not paragraph
The description is broken wherever the surgeon starts a new action on a body part, since a single paragraph often holds several and one action can span two.
Five facts recorded for every action
Body part, objective, approach, device remaining and specimen are captured in fixed columns, the details that later decide each character of the procedure code.
The body part that was freed
Adhesions cut to free a bowel loop are recorded under the bowel, because the guidelines assign a release to the structure liberated rather than the tissue divided.
Integral steps marked as integral
Exploration performed to reach the objective and closure of the incision are noted but not given rows of their own, so the grid does not inflate the procedure count.
Open details turned into a question
Where the narrative leaves a detail unsettled, such as which segment of bowel was involved, the abstraction drafts a neutral question to the surgeon instead of guessing.
Where marks go in HIM-355 Topic 2
Abstractions lose most marks when they copy the procedure title into the grid and call it extraction. The title names an operation; the rows are supposed to record actions, and a title-driven grid misses anything the surgeon did that the heading left out. Recording the adhesions as the body part, instead of the structure they were freed from, is the classic error on a case like this one and shows the guideline went unread. Grids that give exploration and closure their own rows overstate the work performed. Leaving the device column empty without stating that nothing remained looks identical to never checking. Drafts that fill an unsettled detail with the likeliest answer, rather than raising it with the surgeon, turn a documentation gap into a coding decision nobody authorized.
Get an HIM-355 Topic 2 example written to your instructions
Send the HIM-355 Topic 2 instructions, your classroom rubric and the operative report or scenario you were assigned. We write a custom example to those criteria, with the report reproduced, each action given a row, the five facts recorded, integral steps marked and unsettled details raised as questions, back in 24 to 48 hours. The first one costs nothing.
HIM-355 Topic 2 questions, answered
Which part of the operative report matters most?
The narrative description of the procedure, because it is the only part that records actions in sequence. Headings, titles and the list of procedures at the top are summaries written for other purposes, and they omit or compress what the coder needs. Findings and specimens matter as supporting detail. The example reads the narrative first and uses every other part to check it, never to replace it.
Is exploration ever coded on its own?
When exploring the area is the whole procedure, yes, since an inspection with no other root operation is reportable in itself. When the exploration is how the surgeon reached the objective, the ICD-10-PCS guidelines treat it as integral and it is not coded separately. The example marks each exploratory step in the composite narrative and states which of those two situations it belongs to.
What if the report never says what device remained?
Then the record has a gap, and the abstraction says so rather than inferring. Device values in ICD-10-PCS are reported only when a device remains after the procedure is completed, and materials such as sutures and ligatures are treated as integral rather than as devices. If your report is ambiguous about something left in place, the example drafts a question to the surgeon and holds the device value open until it is answered.