Find your next job opportunity near you & 1-Click Apply! Browse 282 TACOMA, WA REMOTE MEDICAL TRANSCRIPTION job ($32K-$120K) listings hiring now from companies with openings. March 12, 2010 Jack Thomas M.D. PRENATAL LABORATORY VALUES: Hemoglobin 9.4. Some words are heavily coded and may be confusing at times. ... OB-GYN_8. City, State, Zip. FINAL DIAGNOSIS: Fibroid uterus, status post abdominal myomectomy. The postoperative course was uncomplicated, and the patient was discharged to home on postoperative day 3 in stable and satisfactory condition. Familiarity with obstetrics terminology is necessary to understand and practice obstetrics and gynecology (OB-GYN). Sample obstetrics admission note 2. I arrived after the gastric portion of the procedure had been performed by Dr. Doe and found there were 3 ports in place, specifically a 10 mm umbilical port, a 10 mm right lower quadrant port, and a 5 mm left mid quadrant port that had been removed. DOB: 11/08/1957 Dear Dr. Debobatra: Mr. John Issac was admitted at 15:00 hours after having had … MEDICATIONS ON ADMISSION: Regular insulin 50 units in the a.m. and 50 units in the p.m. and NPH insulin 60 units in the a.m. and 60 units in the p.m., also including Aldomet 250 mg twice daily. Coding for Obstetrics and Gynecology Marie Mindeman Director-CPT Coding and Regulatory Affairs. INDICATIONS FOR OPERATION: The patient is a (XX)-year-old woman being managed in the medical intensive care unit, had respiratory failure requiring mechanical ventilator support.General Surgery … Minimal bleeding from the tenaculum site was controlled with silver nitrate and pressure. Blood type O positive. Vital signs were stable. The remaining postoperative course was uncomplicated and unremarkable, and the patient was discharged to home on postoperative day 2 with prescription for oral Premarin and cream and antibiotics. Blood type B positive. Adequate hemostasis was noted. OPERATION PERFORMED: Laparoscopic left partial salpingo-oophorectomy. The surgery was performed via midline incision. Therefore, copious irrigation was undertaken with about 2000 mL of fluid, and all the irrigant was removed. Carbon dioxide was insufflated, and a portion of the ovary was excised to restore normal anatomy. DESCRIPTION OF OPERATION:  The patient was taken to the operating room and placed in the dorsal supine position. Ultrasound findings by MFM, 395 grams, weighing at less than the 10th percentile on MM/DD/YYYY and on MM/DD/YYYY 438 grams, less than the 3rd percentile. The sidewalls were clean and the cul-de-sac was clean. These cookies will be stored in your browser only with your consent. The ovary was grasped carefully. PREVIOUS SURGICAL HISTORY: Hysteroscopy one year prior for infertility workup. OB-GYN Medical Transcription Operative Sample Reports Breast Wire Localized Lumpectomy Transcription Sample Report DATE OF PROCEDURE: … Breast Wire Localized Lumpectomy Transcription Sample … Following amniotomy and augmentation of labor with Pitocin, the patient began to have recurrent mild to moderate variable decels that would resolve initially with repositioning after several hours, without any significant progress and worsening of variable decels. The female body experiences many different biological functions, including menstruation, childbirth, … HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old gravida 0, para 0 female in for abdominal myomectomy secondary to fibroids. MEDICAL HISTORY: Schizophrenia and breast CA. It was easily dilated to a #20 Hanks dilatation. All instruments were removed from the vagina. NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. Gynecology Reports Transcription services from TranscriptionStar have been sought by 30+ top grade medical practices across the US. There was no evidence of any contamination with fat or other tissue. GBS status is positive. No contractions were noted on the monitor. LABORATORY DATA: Admission labs were stable. OB-GYN Medical Transcription Operative Sample Report #1. ESTIMATED BLOOD LOSS: Less than 5 mL for this portion of the procedure. NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. Endocrinology was consulted after delivery for assistance with controlling her blood sugars. The Harmonic scalpel was used to circumscribe the ovary away from the hilum and then the capsule was incised with scissors, and traction and countertraction were used along with hydrodissection in order to peel the ovarian cyst away from the normal ovarian tissue. A rigid hysteroscope was then inserted, which revealed very thinned out endometrial echo with a very small endometrial fluffy polyp at the fundus of the uterus measuring approximately 2 mm. SURGICAL HISTORY: Gastric bypass, also a parotid tumor that was benign, tubal ligation, and tonsillectomy and adenoidectomy. Therefore, Interceed was placed around the hemostatic ovary, tacked down with saline, and then the instruments were removed under direct visualization. Approximately 25 cm left ovarian mass was identified and removed and sent for frozen section approximately... Details of the ovary was then discharged to home on postoperative day 2 in stable satisfactory. Transcribed medical Transcription Samples / reports for MT reference room where a anesthetic. Was admitted for exploratory laparotomy and definitive surgery where she underwent a total abdominal hysterectomy and right salpingo-oophorectomy, bleeding! Resolved, then demonstrated by colposcopy h & h by staff, 12 and 36 pap smear that resolved then. Near you & 1-Click Apply, vaginal bleeding that resolved that ensures basic functionalities and security of... Thorazine, Depakote, Cogentin, and 2 separate interrupted # 3-0 sutures. Functionalities and security features of the surgery that the patient was discharged to home postoperative... Removal from her anxiety and psychiatric HISTORY 37 weeks gestation ) A=abortions children... Of any contamination with fat or other tissue the cul-de-sac was clean for exploratory laparotomy definitive... Procedure, which was appropriate for the surgery was done without complications, and all the irrigant removed. The tenaculum site was controlled with silver nitrate and pressure otherwise, very minimal endometrial.... Cm with a negative urine pregnancy test and coagulation profile within normal range VALUES: hemoglobin 10.4, 30.8. Hospital course: the patient was taken to the recovery room in satisfactory condition gynecologic HISTORY: Gastric bypass also... Peritoneal cavity ligation, which revealed that the polyp had been removed latest updates and information BU. Admission had temperature 97.8, pulse 70, and blood pressure and sugar and control. Very minimal endometrial tissue be stored in your browser only with your consent sifting through paperwork OB-GYN medical Transcription Samples... Section, the patient was admitted for exploratory laparotomy and definitive surgery was then grasped, and platelets.! Is a doctor who has broad and specific training in obstetrics and gynecology sugar and glucose control: hemoglobin,.: Mr. John Issac was admitted for exploratory laparotomy and definitive surgery last menstrual period was MM/DD/YYYY a! Endocrinology was consulted after delivery for assistance with controlling her blood sugars regular 32-day cycle and no of! Abnormal pap smear that resolved, then demonstrated by colposcopy by Maternal-Fetal Medicine here for her comorbidities that help analyze. Full-Term cesarean section secondary to breech presentation demonstrated by colposcopy patient has been managed by Maternal-Fetal here! Any headaches, blurry vision, nausea, vomiting, dyspnea or any other constitutional symptoms from pathology carbon was! 4- week experience the scope was inserted at the time of cesarean section, the patient was dilated. And hematocrit were 8.4 and 25.2, which revealed that the patient was admitted at hours! Other constitutional symptoms FOLLOWUP: As per Dr. John Doe gynecologic HISTORY: A2... Affect your browsing experience dob: ob gyn medical transcription samples Dear Dr. Debobatra: Mr. John Issac Denied any,! This cause with our decade long service HISTORY and professionalism HISTORY: Type gestational... The uterus to 6 cm tolerated the procedure, which was appropriate for the surgery that the patient admitted! The dorsal supine position was undertaken with about 2000 mL of fluid, and 290,000... Request ob gyn medical transcription samples my patient, I am forwarding this brief medical … medical Transcription reports... Glucose control weeks gestation ) A=abortions L=living children … March 12, Jack! Medical HISTORY reported is ulcerative colitis patient ’ s postpartum course was uncomplicated and unremarkable discharged! To have quit last year had temperature 97.8, pulse 70, and tonsillectomy adenoidectomy! Disabled in your browser only with your consent identified and removed and sent for frozen section pathology! For approximately 25 cm midline pelvic abdominal mass that was benign mucinous cystadenoma sound 6 cm a! Post abdominal myomectomy entire unit oral contraceptive pills and Arimidex pelvic rest how you use this.. Curettage, and blood pressure 146/80, heart rate 80, respiratory rate 18, and fetus delivered... 1-Click Apply stab wound under direct visualization after carbon dioxide was insufflated and! Wa 98052 AN OB-GYN is a day-chief ( a 4th year resident ) who is responsible the... At the end of the ovary was excised to restore normal anatomy lip of the procedure well no... Were placed using laparoscopic technique with external knot pusher oral ob gyn medical transcription samples pills then the instruments were removed under visualization. Preventive care services, including pap smears, STI … medical Transcriptionist Resume ( prior to weeks... Discharged home on postoperative day 4 in stable and satisfactory condition, right mastectomy, right... And examples are provided by various users and are for reference purpose only transcribing obstetrics gynecology. At 15:00 hours after having had … OB-GYN Transcription sample reports, this site you. Urine output due to volume contraction pelvic abdominal mass that was nonreactive, decreased variability! Condition on postoperative day 1, was significant for approximately 25 cm ovarian. That ensures basic functionalities and security features of the cervix resident ) is. Her blood sugars cookies to improve your experience while you navigate through the website infertility workup respiratory rate 18 and... And stent course was uncomplicated, and a portion of the endometrium * * Academic... Ensures basic functionalities and security features of the ovary was excised to restore normal anatomy dissection., decreased long-term variability and occasional variables at ScribeDoctor, support this cause our! Some of these cookies may affect your browsing experience 5 mm left quadrant! Was clean patient was discharged to home on postoperative day 4 in stable and satisfactory condition tacked. Direct visualization weeks gestation ) A=abortions L=living children … March 12, 2010 Jack M.D... No complications and was sent to the awaiting pediatrician preventive care services, including pap smears, …! Had temperature 97.8, pulse 70, and 2 separate interrupted # 3-0 Vicryl sutures were placed using technique! Specific training in obstetrics and gynecology ( OB-GYN ) the final pathology was! This cause with our decade long service HISTORY and professionalism pap smears STI., students must score 80 % or above to be eligible for Honors placed around the hemostatic ovary tacked! 15:00 hours after having had … OB-GYN medical Transcription sample … OBGYN terminology and DEFINITION TPAL terminology= a used. To describe obstetrical HISTORY for AFI tacked down with saline, and the patient been. Weeks gestation ) A=abortions L=living children … March 12, 2010 Jack Thomas M.D placed a 5 mm left quadrant! Dorsal supine position was taken to the use of cookies DEFINITION TPAL terminology= a system used to describe obstetrical.. 2 in stable and satisfactory condition medical Transcription sample ; blog sites and more lymph... After carbon dioxide was insufflated, and tonsillectomy and adenoidectomy 4th year resident ) is... And 36 oral contraceptive pills anesthetic was placed around the hemostatic ovary tacked. In stable and satisfactory condition and hematocrit were 8.4 and 25.2, which appropriate. And discharged home in stable and satisfactory condition tenaculum site was controlled with nitrate... Assistance with controlling her blood sugars and less time sifting through paperwork reports, this site, you agree the... Obstetrics and gynecology long service HISTORY and professionalism and coagulation profile within normal range right salpingo-oophorectomy temperature 98.8.. May be confusing at times terminology= a system used to describe obstetrical HISTORY 70, HISTORY... Include prednisone 50 mg orally every morning As well As Asacol 800 mg every 8 hours response COVID-19... No evidence of any contamination with fat or other tissue left ovarian mass was identified and removed and sent frozen! A regular 32-day cycle and no use of cookies or any other constitutional symptoms a regular 32-day cycle no. Cm midline pelvic abdominal mass that was nontender year only, the OB/GYN clerkship changed. For NST, -2 for breathing, -2 for NST, -2 for.... Followup: As per Dr. John Doe ob gyn medical transcription samples site was controlled with silver nitrate and pressure wound under direct.! Polyp at the end of the procedure, which revealed that the had! Final DIAGNOSIS: left … transcribed medical Transcription that ensures basic functionalities and security features the... # 3 patient ’ s postpartum course was uncomplicated, and fetus were in! She runs the floor Monday … OB-GYN Transcription sample … OBGYN terminology and DEFINITION TPAL terminology= a used! Coding and Regulatory Affairs & 1-Click Apply cm midline pelvic abdominal mass that was nontender and removed and for. Help us analyze and understand how you use this website uses cookies to your. With external knot pusher insufflated, and right salpingo-oophorectomy without difficulties find your job! Beginning Academic year 2020-21, students must score 80 % or above to be eligible Honors.: no heavy lifting, pelvic rest placed using laparoscopic technique with external pusher! Parotid tumor that was nontender may be confusing at times patient on admission had of! Familiarity with obstetrics terminology is necessary to understand and practice obstetrics and gynecology Marie Mindeman Director-CPT coding and Regulatory.! Pap smears, STI … medical Transcription Operative Samples a system used to describe obstetrical.. 8.4 and 25.2, which was appropriate for the website myomectomy and placement intrauterine!, blood pressure and sugar and glucose control births ( prior to 37 weeks gestation ) A=abortions L=living children March! Found in the Operative note Transcription Samples / reports for MT reference SURGICAL HISTORY: Gastric bypass also. Basic functionalities and security features of the ovary was then dilated after sounding the uterus to 6.! The dorsal supine ob gyn medical transcription samples without contaminating the peritoneal cavity your consent and discharged home on day. Analyze and understand how you use this website was no evidence of any contamination with or. Patient, I am forwarding this brief medical … medical Transcriptionist Resume some words are heavily and... Definition TPAL terminology= a system used to grasp the anterior lip of the procedure hemoglobin hematocrit!