MEDICAL TRANSCRIPTION SAMPLE REPORTS: arthroscopy with subacromial debridement

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.

Thursday 2 August 2012

arthroscopy with subacromial debridement

PREOPERATIVE DIAGNOSES: Right shoulder rotator cuff tear and history of instability.

POSTOPERATIVE DIAGNOSES:

1. Rotator cuff intact with anterior and posterior labral tear.

2. Synovitis and bursitis, right shoulder.

PROCEDURE:

1. Right shoulder arthroscopy with subacromial debridement, decompression.

2. Debridement of glenohumeral joint, anterior and posterior labrum, _____.

BLOOD LOSS: Minimal.

FLUIDS: Crystalloid.

COMPLICATIONS: None.

INDICATIONS FOR SURGERY: A 19-year-old female with multiple shoulder surgeries sustained another injury to the right shoulder. Risks, benefits, and alternatives were discussed. The patient wished to proceed with surgery as that her parents.

OPERATIVE PROCEDURE: The patient was identified, brought to the operating room, and placed in the supine position. After induction of a general anesthetic, the right shoulder was sterilely prepped and draped. Shoulder was inflated with saline. Portal sites established. Findings as follows: The patient was noted to have intact rotator cuff. A small anterior labral tear was identified, which flapped into the joint. Posterior labral tear was also identified and debrided using full-radius. The inferior labrum was grossly intact with the sutures being evident and intact. There was a small notch superiorly, but it did not impinge in the joint. This was checked and then just gently trimmed using the basket forceps. Posterior aspect was intact. The glenohumeral joint showed no evidence of major arthrosis with minimal fraying of the articular cartilage. I carefully inspected the entire cuff in the undersurface, did not notice any full-thickness defect. We then went to the subacromial space, we switched off the cannulas. We went superiorly using a full-radius resector and debridement performed of the thickened bursal tissue and scar tissue. No full-thickness defects were again noted. We then trimmed the undersurface of the acromion using a full radius resector, and after this, we removed all instruments from the shoulder. The shoulder was closed with simple nylon sutures. Sterile dressing applied. The patient tolerated the procedure well. My assistant was essential in this case.

MEDICAL TRANSCRIPTION SAMPLE REPORTS

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