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

Description: Traumatic injury to bilateral upper extremities. Dressing change under anesthesia. This 6 year old was involved in a traumatic accident. She presents today for evaluation and dressing change.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Traumatic injury to bilateral upper extremities.

POSTOPERATIVE DIAGNOSIS: Traumatic injury to bilateral upper extremities.

PROCEDURE: Dressing change under anesthesia.

PREOPERATIVE INDICATIONS: This 6 year old was involved in a traumatic accident. She presents today for evaluation and dressing change.

OPERATIVE PROCEDURE IN DETAIL: The patient was brought to the operating room under the care of Dr. X. He called us intraoperatively to evaluate the hand that had previously been repaired. We were involved to that extent. After removing the bandages, we recognized that more of the tissue had healed than was initially expected. She had good perfusion although the distal aspect of her left long finger. This was better than expected. For this reason, no debridement was done at this time. Dressings were reapplied to include Xeroform and a splint. General Surgery and Orthopedic then carried on the rest of the operation.

Keywords: surgery, bandages, traumatic injury, upper extremities, dressing change, traumatic, dressing, injury,
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