Surgery OP Report Terms For Medical Transcriptionists


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



bulky dressing

Bunnell-type dressing

Coban wrap

compression dressing

dry sterile dressing

fluff dressing

iodoform gauze

Jones dressing

Kerlix dressing



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


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


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
Foley catheter
pneumatic tourniquet
bandage scissors
gloves were changed
gowns were changed
hemostasis was obtained
sponge, needle and instrument counts were correct x3