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
