INPATIENT HOSPITAL Gender: F Age: 48
Preprocedure diagnosis: Mass in left breast
Procedure description: Needle biopsy. Using a needle, took outa tissue sample from the left breast that was previously markedwith a wire.
Postprocedure diagnosis: Benign neoplasm, breast per pathologyreport
1. What is the stated procedure?
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2. What organ or body part is involved?
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3. Is the procedure description what you would expect based onthe name of the procedure?
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4. Was more than one procedure, or a combined procedure,performed?
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5. Review the Key Criteria for Abstracting Root Operations. Towhich question did you answer yes?
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6. Review the definitions of the root operations that answerthis question. Which root operation correctly describes thisprocedure?
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7. Review the Key Criteria for Abstracting the Approach. Whatsurgical approach is used?
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8. Review the Key Criteria for Abstracting the Qualifier. Wasthe procedure diagnostic or therapeutic?
