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Category: Orthopedic Surgery

ORIF of Trimalleolar Ankle Fracture Sample Report

DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE DIAGNOSIS: Trimalleolar ankle fracture on the right. POSTOPERATIVE DIAGNOSIS: Trimalleolar ankle fracture on the right. OPERATION PERFORMED: Open reduction and internal fixation, trimalleolar ankle fracture, …

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Physical Exam Template Examples
Physical Exam Section Transcription Examples for Reference by MTs: PHYSICAL EXAMINATION: Blood pressure 130/84, pulse …
Normal Physical Exam Template For MTs
PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 116/76, pulse 78, respirations 16, temperature 98.8, and O2 …
Physical Exam Template
Physical Exam Template PHYSICAL EXAMINATION: GENERAL: The patient is well developed and nontoxic. VITAL SIGNS: …

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Index Finger Injury Chart Note Sample
Index Finger Injury Chart Note Sample Report DATE OF SERVICE: …
Knee Arthroplasty MCL Reconstruction Sample Report
DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE DIAGNOSES: 1. Rheumatoid arthritis. 2. …
Knee Pain ER Sample Report
DATE OF ADMISSION: MM/DD/YYYY CHIEF COMPLAINT: Bilateral knee pain. HISTORY …

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Dorsal Carpal Ganglion Excision Operative Sample Report
DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE DIAGNOSIS: Right dorsal carpal ganglion. …
Thumb Soft Tissue Mass Excision Sample Report
DATE OF PROCEDURE: MM/DD/YYYY PREOPERATIVE DIAGNOSIS: Left thumb soft tissue …
Calcaneonavicular Coalition Excision Sample Report
Calcaneonavicular Coalition Excision Sample Report DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE …

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Mental Status Examination Medical Transcription Examples
MENTAL STATUS EXAMINATION: Reveals a Hispanic male, well groomed, lying …
Mental Status Exam MT Transcribed Examples
MENTAL STATUS EXAMINATION: APPEARANCE/BEHAVIOR: The patient is disheveled, noticeable bilateral …

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Left Heart Catheterization Medical Transcription Sample Report
DATE OF PROCEDURE: MM/DD/YYYY PROCEDURES PERFORMED: Left heart catheterization. Selective …
Endovascular Stent Graft Repair Sample Report
Endovascular Stent Graft Repair Sample Report DATE OF OPERATION: MM/DD/YYYY …
Mitral Valve Repair Operative Sample Report
DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE DIAGNOSES: 1. Myxomatous mitral valve, …

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Simple Bunionectomy Medical Transcription Operative Sample
DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE DIAGNOSES: 1. Hallux abductovalgus, hammertoe, …
Osteophytes Resection Operative Sample Report
Osteophytes Resection Operative Sample Report DATE OF PROCEDURE: MM/DD/YYYY PREOPERATIVE …
Austin Bunionectomy Medical Transcription Sample Report
DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE DIAGNOSES: 1. Hallux abductovalgus deformity, …

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Obstructive Sleep Apnea Sample Report
DATE OF SERVICE: MM/DD/YYYY REASON FOR VISIT: The patient is …
Persistent Cough and Hoarseness Consult Sample Report
DATE OF CONSULTATION: MM/DD/YYYY REFERRING PHYSICIAN: John Doe, MD REASON …
Sleep Disturbance Consult Sample Report
DATE OF CONSULTATION: MM/DD/YYYY REFERRING PHYSICIAN: John Doe, MD REASON …

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Medial Brow Defect Reconstruction Sample Report
Reconstruction of Right Medial Brow Defect Sample Report DATE OF …
Split-Thickness Skin Graft Procedure Sample Report
DATE OF PROCEDURE: MM/DD/YYYY PREOPERATIVE DIAGNOSIS: Open wound, left dorsolateral …
Wide Local Excision of Nasal Tip Skin …
DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE DIAGNOSIS: Skin cancer of the …

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