Medical Transcription Samples

Neurosurgical Transcribed Operative Sample Report / Transcription Example

2012-02-05T06:29:00.000-08:00

DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE DIAGNOSIS: Spinal stenosis, L3-L4, secondary to degenerative spondylolisthesis, status post L4-L5 fusion. POSTOPERATIVE DIAGNOSIS: Spinal stenosis, L3-L4, secondary to degenerative spondylolisthesis, status post L4-L5 fusion. OPERATIONS PERFORMED: 1. Anterior interbody fusion with reduction of spondylolisthesis and placement of CoRoent

Blepharoplasty / Endotine Browlift Medical Transcription Operative Procedure Transcribed Sample Report / Example

2012-01-30T04:15:00.000-08:00

DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE DIAGNOSES: 1. Brow ptosis with asymmetry. 2. Bilateral upper lid blepharochalasis. 3. Bilateral lower lid blepharochalasis. 4. Submental lipodystrophy. POSTOPERATIVE DIAGNOSES: 1. Brow ptosis with asymmetry. 2. Bilateral upper lid blepharochalasis. 3. Bilateral lower lid blepharochalasis. 4. Submental lipodystrophy. OPERATIONS PERFORMED: 1. Right

General Surgery Consultation Medical Transcription Sample Report / Example

2012-01-17T03:41:00.000-08:00

DATE OF CONSULTATION: MM/DD/YYYY REFERRING PHYSICIAN: Jane Doe, MD REASON FOR CONSULTATION: Evaluation of ileostomy protrusion above the level of the skin. HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who came to the hospital with complaint of left-sided pain, left-sided upper extremity and chest pain, and weakness. This patient underwent emergency operation of the

Podiatric / Foot Surgery Medical Transcription Operative Sample Report

2012-01-14T05:37:00.000-08:00

DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE DIAGNOSES: 1. Left foot middle facet subtalar joint coalition. 2. Left foot plantar fasciitis. POSTOPERATIVE DIAGNOSES: 1. Left foot middle facet subtalar joint coalition. 2. Left foot plantar fasciitis. OPERATIONS PERFORMED: 1. Left foot excision of middle facet coalition with subtalar joint arthroereisis and insertion of GraftJacket spacer. 2

Ob-Gyn Medical Transcription Operative Procedure Sample Report

2012-01-13T06:01:00.000-08:00

DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE DIAGNOSIS: Symptomatic leiomyomatous uterus. POSTOPERATIVE DIAGNOSES: 1. Symptomatic leiomyomatous uterus. 2. Pelvic endometriosis. 3. Dense right adnexal adhesions. OPERATIONS PERFORMED: 1. Laparoscopic-assisted vaginal hysterectomy with right salpingo-oophorectomy. 2. Lysis of adhesions. 3. Ablation of pelvic endometriosis. SURGEON: John

Rhytidectomy, Brow Lift, Blepharoplasty MT Operative Sample Report

2012-01-09T06:56:00.000-08:00

DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE DIAGNOSIS: Aging face. POSTOPERATIVE DIAGNOSIS: Aging face. OPERATIONS PERFORMED: Rhytidectomy, endoscopic brow lift, upper lid blepharoplasty, lower lid blepharoplasty and periorbital fat transfer. SURGEON: John Doe, MD ANESTHESIA: General endotracheal. ESTIMATED BLOOD LOSS: Negligible. FLUIDS: Crystalloids.

Renal Consultation Medical Transcription Sample Report / Example

2012-01-08T04:55:00.000-08:00

DATE OF CONSULTATION: MM/DD/YYYY REFERRING PHYSICIAN: John Doe, MD REASON FOR CONSULTATION: Abnormal renal function. HISTORY OF PRESENT ILLNESS: The patient is an (XX)-year-old female who was admitted to the hospital after presenting with respiratory distress, ultimately requiring intubation because of a combination of x-ray findings suggestive of both airspace disease as well as

Cardiovascular Consultation Medical Transcription Sample Report / Example

2012-01-08T03:29:00.000-08:00

DATE OF CONSULTATION: MM/DD/YYYY REFERRING PHYSICIAN: John Doe, MD REASON FOR CONSULTATION: Questionable syncope and atrial fibrillation with rapid ventricular response. HISTORY OF PRESENT ILLNESS: The patient is an (XX)-year-old female with a history of coronary artery disease with non-Q-wave myocardial infarction, angioplasty, stent delivery to the LAD and reduced ejection fraction of

Pulmonary Consultation Medical Transcription Transcribed Sample Report

2012-01-07T06:35:00.000-08:00

DATE OF CONSULTATION: MM/DD/YYYY REFERRING PHYSICIAN: John Doe, MD REASON FOR CONSULTATION: Not dictated. HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who is status post coronary artery bypass grafting x5 vessels. He is orally intubated and sedated and pulmonary consultation is requested. History was obtained from chart review. The patient began to have chest pain,

Internal Medicine Consultation Medical Transcription Sample Report / Example

2012-01-06T05:10:00.000-08:00

DATE OF CONSULTATION: MM/DD/YYYY REFERRING PHYSICIAN: John Doe, MD REASON FOR CONSULTATION: Lower abdominal pain. HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female, who said that she was doing fine. She started having abdominal pain located in the lower part of the abdomen; this started yesterday. She had associated leg pain and shoulder pain. The pain was predominantly

Infectious Disease (ID) Consultation Medical Transcription Sample Report

2012-01-05T10:35:00.000-08:00

DATE OF CONSULTATION: MM/DD/YYYY REFERRING PHYSICIAN: Jane Doe, MD REASON FOR CONSULTATION: Abscess in the left upper chest. HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old woman who reportedly has prior history of right upper extremity DVT. She states that she presented to the hospital emergency department because of problems with pain and swelling in the left

Neuropsychology Consultation Medical Transcription Sample Report

2012-01-03T06:51:00.000-08:00

DATE OF CONSULTATION: MM/DD/YYYY REFERRING PHYSICIAN: John Doe, MD REASON FOR CONSULTATION: To evaluate the patient's current cognitive and emotional function following central nervous system compromise. DIAGNOSIS ON PRESENTATION: Stroke. HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman who was transferred from an outside hospital with right-sided

Colonoscopy and ERBE Argon Laser Cautery Medical Transcription Sample

2012-01-02T05:38:00.000-08:00

DATE OF PROCEDURE: MM/DD/YYYY PREOPERATIVE DIAGNOSIS: Hemoccult-positive stools, melena and acute blood loss anemia, on anticoagulation therapy with aspirin, Plavix and heparin, not explained by upper endoscopic findings. POSTOPERATIVE DIAGNOSES: 1. Large, extensive rectal prolapse, ischemic-type ulcerations with visible vessel and active bleeding, photocoagulated with ERBE argon laser for

Corpectomy / Decompression of Spinal Canal Medical Transcription Sample

2012-01-02T03:40:00.000-08:00

DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE DIAGNOSES: 1. Cervical spinal stenosis with myelopathy. 2. Severe cervical congenital abnormality and scoliosis. POSTOPERATIVE DIAGNOSES: 1. Cervical spinal stenosis with myelopathy. 2. Severe cervical congenital abnormality and scoliosis. OPERATION PERFORMED: C4 corpectomy with decompression of the spinal canal and nerve elements with

ENT Procedure Medical Transcription Transcribed Operative Sample Report

2012-01-02T03:15:00.000-08:00

DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE DIAGNOSES: 1. Deviated nasal septum, left. 2. Nasal obstruction. 3. Turbinate hypertrophy with no response to topical nasal decongestant. 4. Rhinitis, pharyngitis and halitosis. POSTOPERATIVE DIAGNOSES: 1. Deviated nasal septum, left. 2. Nasal obstruction. 3. Turbinate hypertrophy with no response to topical nasal decongestant. 4. Rhinitis,

Colonoscopy and Polypectomy Medical Transcription Operative Sample

2011-12-30T05:42:00.000-08:00

DATE OF PROCEDURE: MM/DD/YYYY PREOPERATIVE DIAGNOSIS: Screening examination. POSTOPERATIVE DIAGNOSIS: Multiple colonic polyps. OPERATION PERFORMED: Total colonoscopy and multiple polypectomies including snare polypectomy. ENDOSCOPIST: John Doe, MD ANESTHESIA: IV fentanyl, Versed and Phenergan in incremental doses. DESCRIPTION OF PROCEDURE: Digital examination and inspection was

Colonoscopy to Ileotransverse Anastomosis Medical Transcription Sample

2011-12-30T04:28:00.000-08:00

DATE OF PROCEDURE: MM/DD/YYYY PREOPERATIVE DIAGNOSES: 1. High-risk colon polyp surveillance status post right hemicolectomy with ileotransverse anastomosis for large tubulovillous adenoma of the transverse colon. 2. History of small bowel carcinoid tumor. POSTOPERATIVE DIAGNOSES: 1. Small benign polyps and superficial, possibly ischemic, ulcers of the side-to-side ileotransverse colon

Orthopedic - Arthroscopy and Meniscectomy Medical Transcription Sample

2011-12-30T03:58:00.000-08:00

DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE DIAGNOSIS: Right knee lateral meniscus tear. POSTOPERATIVE DIAGNOSES: 1. Right knee lateral meniscus tear. 2. Loose body. 3. Lateral femoral condyle chondral lesion. OPERATION PERFORMED: Right knee diagnostic and operative arthroscopy with arthroscopic partial lateral meniscectomy, arthroscopic loose body removal and arthroscopic lateral

Cervical Decompression Medical Transcription Operative Sample Report

2011-12-29T06:08:00.000-08:00

DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE DIAGNOSIS: C6-7 disk herniation with radiculopathy, right. POSTOPERATIVE DIAGNOSIS: C6-7 disk herniation with radiculopathy, right. OPERATION PERFORMED: Anterior cervical decompression with partial vertebrectomy and fusion, C6-7, using right iliac bone graft and Eagle plating. SURGEON: John Doe, MD ASSISTANT: Jane Doe, PA ANESTHESIA:

Hand Surgery Medical Transcription Transcribed Operative Sample Report

2011-12-28T05:21:00.000-08:00

DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE DIAGNOSES: 1. Right small finger flexor tendon contracture. 2. Proximal interphalangeal joint contracture. 3. Distal interphalangeal joint contracture. POSTOPERATIVE DIAGNOSES: 1. Right small finger flexor tendon contracture and adhesions. 2. Proximal interphalangeal joint contracture. 3. Distal interphalangeal joint contracture. 4.

Lumpectomy and Axillary Lymph Node Sampling Medical Transcription Sample

2011-12-27T06:13:00.000-08:00

DATE OF PROCEDURE: MM/DD/YYYY PREOPERATIVE DIAGNOSES: 1. Left breast mass. 2. Atypia, fine-needle aspiration. POSTOPERATIVE DIAGNOSIS: Left breast cancer. PROCEDURES PERFORMED: 1. Left lumpectomy. 2. Left axillary lymph node sampling. SURGEON: John Doe, MD ASSISTANT: Jane Doe, MD ESTIMATED BLOOD LOSS: 50 mL. ANESTHESIA: MAC. TUBES AND DRAINS: 10 mm Blake

Total Knee Arthroplasty Medical Transcription Operative Sample Report

2011-12-06T07:46:00.001-08:00

PREOPERATIVE DIAGNOSIS: Left knee degenerative joint disease. POSTOPERATIVE DIAGNOSIS: Left knee degenerative joint disease. OPERATION PERFORMED: Left total knee arthroplasty. SURGEON: John Doe, MD ASSISTANT: Jane Doe, MD ANESTHESIA: General endotracheal anesthesia. ESTIMATED BLOOD LOSS: 50 mL. COMPLICATIONS: None. DESCRIPTION OF OPERATION: Once consent was obtained, the patient

Austin Bunionectomy Medical Transcription Transcribed Sample Report

2011-12-03T06:24:00.001-08:00

DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE DIAGNOSIS: Hallux abductovalgus deformity, left first metatarsal. POSTOPERATIVE DIAGNOSIS: Hallux abductovalgus deformity, left first metatarsal. OPERATION PERFORMED: Austin bunionectomy with internal fixation, left first metatarsal. SURGEON: John Doe, D.P.M. HEMOSTASIS: Pneumatic ankle tourniquet set at 250 mmHg. ANESTHESIA: MAC with local

Hematology - Oncology Consult Medical Transcription Transcribed Sample

2011-11-07T06:30:00.000-08:00

DATE OF CONSULTATION: MM/DD/YYYY REQUESTING PHYSICIAN: John Doe, MD CONSULTANT: Jane Doe, MD REASON FOR CONSULTATION: Hematological clearance. Thank you, Dr. Doe, for allowing us to participate in this patient's medical care. HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old female who has a history of von Willebrand disorder, which has never been confirmed. She has

ENT Consult Medical Transcription Transcribed Sample Report / Example

2011-11-07T04:02:00.000-08:00

DATE OF CONSULTATION: MM/DD/YYYY REFERRING PHYSICIAN: John Doe, MD CONSULTANT: Jane Doe, MD REASON FOR CONSULTATION: Acute dizziness. IMPRESSION: 1. Acute exacerbation of chronic benign positional vertigo. 2. Underlying complex medical history including acute exacerbation of chronic obstructive pulmonary disease, depression, diabetes, and hypertension. 3. No evidence of