MEDICAL TRANSCRIPTION SAMPLE REPORTS: Operative Report Pacemaker generator replacement

Medical Transcription

Medical transcription is one of the fastest-growing profession in the country today.

Medical transcription offers excellent opportunity to housewives, ex-servicemen, graduate fresh or experienced, especially the newly passed ones. It is also a high income career for the graduates. You can even sit at your home and earn money from home feasibly through medical transcription career, and one can organize his/her own work timings and avoid travel to the works for and thus earn more than the usual office goers.

Nature of job, doctors will dictates the patients’ information, which we will receive in wave format through voice mail or dictaphone which consists of medical datas, which we have to type.

Transcription process is conversion of voice to electronic text form. As this process deals medical data documentation, so this is called medical transcription. The person who deals with medical data process is called Medical Transcriptionist.

Any person can do home based medical transcription program, those who are interested to learn, who able to grasp accents’ of dictators’ voice, who able to understand English, who able to form sentences grammatically and finally, who wants to earn money shortly from home or office.

There are many institutions that providing free home based medical transcription training through internet with their own “terms and condition” and time limits, duration. To avail home based medical transcription training you should computer laptop or desktop with UPS, phone and internet connection for communications. They would design the program accordingly where one can learn medical transcription from home.

Home based Medical transcription Training program duration may be 2 to 4 months.

After successful completion of home medical transcription training from institute based on your quality and quantity, you will be offered a home based job medical transcription immediately, and you are supposed to sign an agreement and can start medical transcription job from home and can start earning from home. Companies will provide you files through internet which has to be transcribed.

Based on your quality and quantity, remuneration will be fixed with incentives per month and remuneration will be gradually increased as your experience increases. One can start earn initially low, but gradually can increase with incentives as experience increases.

Quality - the document should be without error and should not commit error beyond the limit. Files should be submitted with minimum 90% accuracy to company by the medical transcriptionist and to the client, 99.5% accuracy after QC/QA. Quantity - a transcriptionist should be able to transcribe minimum of 350 lines per day, initially after successful training.

Main advantage of taking home based medical transcription work, one can organize their own work timings. They can reduce your traveling time 2 to 4 hours, so that can spend more time in working to earn more.

Wednesday, 25 July 2012

Operative Report Pacemaker generator replacement

PREOPERATIVE DIAGNOSIS:
1. End-of-service with pacemaker generator.
2. Pacemaker dependent.

POSTOPERATIVE DIAGNOSIS:
1. End-of-service with pacemaker generator.
2. Pacemaker dependent.

PROCEDURE:                 Pacemaker generator replacement.

ANESTHESIA:                 Monitored anesthesia care plus local.

ESTIMATED BLOOD LOSS:         None.

INDICATIONS:                 The patient is a very pleasant 88-year-old gentleman status post initial single-chamber ventricular pacemaker insertion 01/10/96, and status post pacemaker generator replacement 02/12/02, where recent testing found that the pacemaker was at elective replacement interval. He is pacemaker dependent. He was referred for pacemaker generator replacement. The indications, risks, benefits of procedure were explained to the patient as well as to his wife and neice. He understood and consented for the operation.

FINDINGS:                 The explanted pacemaker is a St. Jude Medical model #5136, serial #605300. The chronic right ventricular lead is a St. Jude Medical model # 1246, T/58, serial #CB18308. The implanted pacemaker is a St. Jude Medical Zephyr XL SR, single chamber rate responsive pacemaker, model #5626, serial #1984162. Pacing parameters for the right ventricular lead, R-waves were not measured as he is pacemaker dependent, impedance 648 ohms, and pacing threshold 0.4 volts.

PROCEDURE IN DETAIL:     A time-out was performed prior to start of the operation. The patient was correctly identified as well as the procedure. With the patient under monitored anesthesia care, the patient's left upper chest and neck were prepped with DuraPrep and draped sterilely. A 1% Xylocaine was infiltrated locally over the more superior of the two pacemaker scars. The pacemaker scar was incised. The subcutaneous tissues were divided with electrocautery. The fibrous capsule surrounding the pacemaker generator was opened and the pacemaker explanted. The lead was loosened and removed from the pacemaker generator and quickly attached to the pacemaker cable for pacing and testing, as the patient is pacemaker dependent. Pacing parameters were excellent. The lead was then inserted into the receptacle of the pacemaker generator and tightened down.

The pocket was irrigated with antibiotic solution. Hemostasis was fine. The generator was inserted into the pocket. The incision was closed in layers with continuous Vicryl sutures including the subcuticular layer. Dermabond and a Coverlet were applied.

The patient tolerated the procedure well and there were no complications. Sponge, instruments, and needle counts were correct. The patient was transported to the post anesthesia care unit in stable condition.

MEDICAL TRANSCRIPTION SAMPLE REPORTS

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