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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ORIF - Mandible Fracture
Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36. Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.

ORIF - Talus
Hawkins IV talus fracture. Open reduction internal fixation of the talus, medial malleolus osteotomy, and repair of deltoid ligament.

ORIF & Cervical Fusion
Open reduction and internal fixation (ORIF) of comminuted C2 fracture. Posterior spinal instrumentation C1-C3, using Synthes system. Posterior cervical fusion C1-C3. Insertion of morselized allograft at C1to C3.

ORIF & Closed Reduction
Open reduction and internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint and closed reduction casting of the right forearm.

ORIF Mandibular Fracture & Dental Implant Removal
Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible. The patient fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture.

ORIF of Left Distal Radius
Open reduction and internal fixation of left distal radius.

ORIF Wrist - Acumed Locking Plate
Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate. Closed displaced angulated fracture of the right distal radius.

ORIF, Closed Reduction, Screw Fixation, Etc.
Open reduction internal fixation (ORIF) with irrigation and debridement of open fracture. Closed reduction and screw fixation of right femoral neck fracture. Retrograde femoral nail using a striker T2 retrograde nail. Irrigation and debridement of knee and elbow abrasions.

OssaTron Extracorporeal Shockwave Therapy
OssaTron extracorporeal shockwave therapy to right lateral epicondyle. Right lateral epicondylitis.

Osteosynthesis
Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip. Osteosynthesis of acetabular fracture on the left, complex variety and total hip replacement.

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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