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

The branch of medical science that treats disease or injury by operative procedures.



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Arthroscopy - Shoulder
Partial rotator cuff tear, left shoulder. Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.

Arthroscopy & Chondroplasty
Diagnostic arthroscopy with partial chondroplasty of patella, lateral retinacular release, and open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws. Grade-IV chondromalacia patella and patellofemoral malalignment syndrome.

Arthroscopy Shoulder/Knee
Right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection, carpal tunnel release, left knee arthroscopy, and partial medial and lateral meniscectomy.

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.

Ash Split Venous Port
Ash split venous port insertion. The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion.

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

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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