Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Orthopedic

The branch of surgery and medicine concerned with the correction or reconstruction of skeletal and spinal deformities.

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Discectomy, Osteophytectomy, & Foraminotomy
Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs

Discharge Summary - ATV Accident
Trauma/ATV accident resulting in left open humerus fracture.

Discharge Summary - Hip Surgery
A 47-year-old female with a posttraumatic AV in the right femoral head.

Redo L4-5 diskectomy, left - recurrent herniation L4-5 disk with left radiculopathy.

Diskectomy & Fusion
Degenerative disk disease at L4-L5 and L5-S1. Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.

Dorsal Extensor Compartment Release
Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis. Release of first dorsal extensor compartment.

Dorsal Ganglion - Excision
Excision dorsal ganglion, right wrist. The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field.

Dorsal Ramus & Branch Block
Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block for sacroiliac joint pain. Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.

Dupuytren Disease Excision
Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger. The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort.

Elbow Manipulation
Left elbow manipulation and hardware removal of left elbow.

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NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples