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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Arthroscopy, Arthrotomy, Bankart lesion repair
Diagnostic arthroscopy exam under anesthesia, left shoulder. Debridement of chondral injury, left shoulder. Debridement, superior glenoid, left shoulder. Arthrotomy. Bankart lesion repair. Capsular shift, left shoulder (Mitek suture anchors; absorbable anchors with nonabsorbable sutures).

Arthroscopy, Meniscoplasty, & Chondroplasty
Arthroscopy of the left knee, left arthroscopic medial meniscoplasty of medial femoral condyle, and chondroplasty of the left knee as well. Chondromalacia of medial femoral condyle. Medial meniscal tear, left knee.

Arthrotomy & I&D
Hemarthrosis, left knee, status post total knee replacement, rule out infection. Arthrotomy, irrigation and debridement, and polyethylene exchange, left knee. No complications were encountered throughout the procedure.

Arthrotomy & Ostectomy & Capsular Mass Excision
Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee. Soft tissue mass and osteophyte lateral femoral condyle, right knee.

Arthrotomy & Subscapularis Tendon Repair
Arthrotomy, removal humeral head implant, right shoulder. Repair of torn subscapularis tendon (rotator cuff tendon) acute tear. Debridement glenohumeral joint. Biopsy and culturing the right shoulder.

Aspiration - Knee Joint
Erythema of the right knee and leg, possible septic knee. Aspiration through the anterolateral portal of knee joint.

Austin Bunionectomy
Austin bunionectomy with internal screw fixation, first metatarsal, left foot.

Austin-Akin Bunionectomy
Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint. Weil osteotomy with internal screw fixation, first right metatarsal. Arthroplasty, second right PIP joint.

Austin-Moore Bipolar Hemiarthroplasty
Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup. Displace subcapital fracture, left hip.

Back & Leg Pain - Discharge Summary
Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy. Chronic pain syndrome.

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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