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: Shiley Tracheostomy Tube Insertion

Description: Insertion of a #8 Shiley tracheostomy tube. A #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch. Dissection was carried down using Bovie electrocautery to the level of the trachea.
(Medical Transcription Sample Report)

OPERATION: Insertion of a #8 Shiley tracheostomy tube.

ANESTHESIA: General endotracheal anesthesia.

OPERATIVE PROCEDURE IN DETAIL: After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.

Next, a #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch. Dissection was carried down using Bovie electrocautery to the level of the trachea. The 2nd tracheal ring was identified. Next, a #11-blade scalpel was used to make a trap door in the trachea. The endotracheal tube was backed out. A #8 Shiley tracheostomy tube was inserted, and tidal CO2 was confirmed when it was connected to the circuit. We then secured it in place using 0 silk suture. A sterile dressing was applied. The patient tolerated the procedure well.

Keywords: surgery, tracheostomy, shiley tracheostomy tube, sternal notch, bovie electrocautery, tracheostomy tube, electrocautery, endotracheal, shiley, tube,
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