Surgery OP Report Terms For Medical Transcriptionists


COMMON WORDS & PHRASES IN OPERATIVE REPORTS:
 

Common opening sentence in operative reports:
 
The patient was taken to the operating room       
 
The patient was taken to the operating suite
 
The patient was taken to surgery
 
 
The patient was placed in the _____ position (one of the following common positions):
 
dorsal position

dorsal supine position

Fowler position
 
jackknife position

lateral decubitus position

lateral recumbent position

leapfrog position

lithotomy position

low lithotomy position

Mayo-Robson position

prone position

reverse Trendelenburg position

semi-Fowler position

semiprone position

Sims position

sitting position

steep Trendelenburg position

supine position

Trendelenburg position
 

The patient was given _____ anesthesia (one of the following common types of anesthesia)
 
 
Bier block

endotracheal anesthesia

epidural anesthesia

general anesthesia

general via LMA

IV conscious sedation

IV sedation

laryngeal mask airway (LMA)

MAC anesthesia

scalene block

spinal anesthesia

wrist block anesthesia

 
Incision was closed using ______ sutures (one of the following common sutures)
 
 
bioabsorbable suture
 

Biosyn suture
 

braided Ethibond suture
 

braided Mersilene suture
 

braided Nurolon suture
 

braided nylon suture
 

braided polyester suture
 

braided silk suture
 

braided Vicryl suture
 

braided wire suture
 

buried interrupted (2-0, 3-0, 4-0, etc) Vicryl sutures
 

catgut suture
 

chromic catgut suture 
 

chromic suture
 

Dexon suture
 

double-armed suture
 

Dupuytren suture
 

Ethibond suture
 

Ethilon suture
 

fast-absorbing plain gut suture
 

figure-of-eight interrupted suture
 

Gore-Tex suture
 

Heaney suture
 

horizontal mattress suture
 

interlocking suture
 

Kirschner suture
 

Mersilene suture
 

Monocryl suture
 

Nurolon suture
 

nylon suture
 

PDS suture
 

Prolene suture
 

pursestring suture
 

silk suture
 

stay suture
 

subcuticular suture
 

suture ligature
 

Vicryl suture
 

_____ dressing (one of the following) was placed:
 
 
4 x 4s
 

ABD dressing
 

Ace wrap
 
 
Adaptic gauze
 

bacitracin
 

benzoin
 

bulky dressing
 

Bunnell-type dressing
 

Coban wrap
 

compression dressing
 

dry sterile dressing
 

fluff dressing
 

iodoform gauze
 

Jones dressing
 

Kerlix dressing
 

Kling
 

Mastisol
 

neoprene dressing
 

nonadherent dressing
 

Opsite dressing
 

Polar Care ice pack
 

pressure dressing
 

Ray-Tec dressing
 

saline-soaked Kerlix gauze
 

scrotal dressing
 

scrotal support
 

sterile bulky gauze
 

sterile compression dressing
 

Steri-Strips
 

Tegaderm dressing
 

Tegasorb dressing
 

Telfa gauze dressing
 

thumb spica splint
 

TubiGrip dressing
 

Vi-Drape dressing
 

Webril dressing
 

wet-to-dry dressing
 

Xeroform dressing/gauze
 
 
Drains used:
 
 
Blake drain
 

Foley catheter to gravity
 
 
fully fenestrated drain
 

Hemovac drain
 

Indwelling double-J stent
 

Jackson-Pratt (JP) drain
 

Penrose drain
 
 
Incisions used:
 
 
anteromedial portal incision
 

Bruner incision
 
 
circumferential incision
 

curvilinear incision
 

elliptical incision
 

hemitransfixion incision
 

inframammary incision
 

infraumbilical incision
 

Killian incision
 

left upper quadrant incision
 

linear incision
 

longitudinal incision
 

low transverse incision
 

midline incision
 

Pfannenstiel incision
 

previously made incision
 

punctate incision
 
radial incision
 

semielliptical incision
 

splitting incision
 

stab incision
 

supraclavicular incision
 

suprapubic incision
 

umbilical incision
 

vertical stab incision
 

Weber-Fergusson incision
 
 
Cautery used:
 
 
bipolar cautery
 

Bovie cautery
 

electrocautery
 

monopolar cautery
 
 
needlepoint cautery
 
 
needle tip cautery
 
 
suction cautery
 
 
Types of dissection:
 
 
careful dissection
 

deep dissection
 

meticulous dissection
 

sharp and blunt dissection
 
 
Ending sentence in operative reports:
 
 
The patient tolerated the procedure well and was discharged in stable condition to the recovery room.
 
 
The patient tolerated the procedure well and recovered without incident.
 
 
Other common phrases in operative reports:
 
 
prepped and draped in sterile fashion
 
 
hemostasis was obtained with electrocautery/bipolar cautery, etc
 
 
Esmarch bandage
 
 
mmHg
 
 
Foley catheter
 
 
pneumatic tourniquet
 
 
exsanguination
 
 
bandage scissors
 
 
gloves were changed
 
 
gowns were changed
 
 
hemostasis was obtained
 
 
sponge, needle and instrument counts were correct x3

 






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