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  Medical Transcription Industry News
22
Medical transcriptionists are professionals who transcribe dictations done by healthcare professionals. MTs take the verbal dictation and type it into an electronic record for the patent's permanent record. Here is an example of a finished report in the specialty of orthopedics:

OPERATION: Arthroscopy of the left knee with meniscectomy.
PROBLEM BEFORE/ CAUSING SURGERY: Meniscus torn on left knee and problems with bone of left knee.
RESULTS FOLLOWING SURGERY: Both issues repaired - tear in meniscus repaired and cleaned of scar tissue
NAME OF OPERATION:  Meniscectomy and arthroscopy of left knee.
ANESTHESIA USED FOR OPERATION: Spinal anesthesia administrered.
DURATION OF SURGERY: 32 minutes.
FLUIDS GIVEN: 100cc of Crystalloid solution
PROCESS: Preparation for surgery was completed on the unit and afterward the patient was taken by stretch to the OR (operating room). Spinal anesthetic was administered by Dr. B. Steele.

To further prepare for the operation, the patient was lay down and covered. The knee was inspected for motion range. An incision was then made to insert the arthroscope. Upon the arrival of the arthroscope in the correct position, fluids were pumped into the knee. The meniscus tear was repaired as well as the cartilage and scar tissue of the patella.

The arthroscope was taken out without damaging the body. There was not a lot of bleeding but bandages were applied from the toes to the thigh as protocol.
The patient was taken to recovery with the spinal still in. The patient was doing fine. Full assessment was done in recovery.

POST-OP INSTRUCTIONS: The patient can place weight on the leg as much as can be endured. The knee and ankle must be regularly stretched. Crutches are permitted for 1-2 days as needed. Medications will be prescribed for swelling. Elevation and application of ice are imperative to recovery.
Patient is to have a post-op appointment in 7-10 days where physical therapy can be discussed.

A medical transcriptionist's job is very important for communicating between medical units.
Posted in: Latest News

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