Transcribed Medical Transcription Sample Reports and Examples
MT HelpLine Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Neurosurgery

Surgery of the nervous system, including nerves, the brain or spinal cord.



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Shunt Revision - 3
Ventriculoperitoneal shunt revision with replacement of ventricular catheter and flushing of the distal end.

Skull Base Reconstruction
Squamous cell carcinoma of right temporal bone/middle ear space. Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.

Spine Fusion
Anterior spine fusion from T11-L3. Posterior spine fusion from T3-L5. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.

Suboccipital Craniectomy
Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.

Temporal Artery Biopsy
Bilateral temporal artery biopsy. Rule out temporal arteritis.

Temporal Artery Biopsy - 1
Headaches, question of temporal arteritis. Bilateral temporal artery biopsies.

Thoracic Discectomy
Thoracic right-sided discectomy at T8-T9. The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9.

Ulnar Nerve Transposition
Subcutaneous ulnar nerve transposition. A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve. Dissection was carried down to the ulnar nerve.

Vein Stripping
Chronic venous hypertension with painful varicosities, lower extremities, bilaterally. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, bilaterally.

Ventricular Drain Catheter Insertion
Burr hole and insertion of external ventricular drain catheter.

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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