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: I&D & Wound Closure - Scalp Lacerations

Description: Incision and drainage (I&D) with primary wound closure of scalp lacerations. The patient is a middle-aged female, who has had significant lacerations to her head from a motor vehicle accident. The patient was taken to the operating room for an I&D of the lacerations with wound closure.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Scalp lacerations.

POSTOPERATIVE DIAGNOSIS: Scalp lacerations.

OPERATION PERFORMED: Incision and drainage (I&D) with primary wound closure of scalp lacerations.

ANESTHESIA: GET.

EBL: Minimal.

COMPLICATIONS: None.

DRAINS: None.

DISPOSITION: Vital signs stable and taken to the recovery room in a satisfactory condition.

INDICATION FOR PROCEDURE: The patient is a middle-aged female, who has had significant lacerations to her head from a motor vehicle accident. The patient was taken to the operating room for an I&D of the lacerations with wound closure.

PROCEDURE IN DETAIL: After appropriate consent was obtained from the patient, the patient was wheeled out to the operating theater room #5. Before the neck instrumentation was performed, the patient's lacerations to her scalp were I&D'ed and closed. It was noted that the head was significantly contaminated with blood as well as mangled. It was decided at that time in order to repair the lacerations appropriately, the patient would undergo cutting of her hair. This was shaved appropriately with shavers. Once this was done, the scalp lacerations were copiously irrigated with a scrubbing brush, hexedine solution together with peroxide. Once this was appropriately debrided with regards to the midline incision with the scalp going through the midline of her skull as well as the incision on the left aspect of her scalp, the wounds were significantly irrigated with normal saline. No significant debris was appreciated. Once this was done, staples were used to oppose the dermal edges together. The patient was subsequently dressed sterilely using bacitracin ointment, Xeroform, 4x4s, and tape. The neck procedure was subsequently performed.

Keywords: surgery, drainage, incision, primary wound closure, lacerations, wound closure, scalp lacerations, scalp, i&d,
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