Sample operative reports

• Sample OR reports - Irish
  • Here's another good resource for op samples - sm
  • MT Desk also has samples. - nm
  • Thanksgiving - Irish
  • Sample operative reports - pauline
  • mt911.com has sample reports. I have - JD

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YES....  www.mtbot.com

Just type surgical reports (or whatever you're looking for) in the search engine.  There are tons of reports in there. 

This is a great site for sample op reports.

http://www.stedmans.com/AtWork/section.cfm/27

I will be starting a new Cardiology acct. I would appreciate any sample reports out there. I have googled and googled to no avail. I have done Cardiology, although it has been many years, but never procedure reports.

Thank you in advance.

Hello everyone!

Can anyone help with a site for sample OR reports particularly diskectomy?

Thank you!

Here are some more sites with op sample reports.

http://www.mtscribes.com/samples.html

http://medicaltranscriptionwordhelp.synthasite.com

Looking for a good web site to help with oncology; chemo meds and such.

TIA!!  -have a good weekend

Hi everyone, I was wondering if anyone knew of any good websites for medical equipment and/or websites to help with Op notes.  Much appreciated!! 

We all know they should, but my point was most won't. But then again, I do remember instances where it was addressed with some of the worst ones, and they improved for a while and back to the same thing.  One radiologist everybody hated typing had a very thick Latin accent, and I ran into him on the elevator and he asked me if I type his dictation, to which I replied in the affirmative, and he said, "Good luck to you, brave lady"!!!!!  Then he would have the audacity to complain to our supervisor that we left too many blanks, that he says the same thing every time, why do we leave blanks!  The nerve!  She did tell him that he was difficult to understand, but do you think he changed?  No.  One of the reasons we could not understand a lot is because he would turn the x-ray films as he was dictating, which would be very noisy, and then he would have the machine on speaker and turn his head from side to side as he'd dictate.  Nice!  But did he stop after being told this?  No.  Nuf said, really.  Just one tiny example. 

What is the most popular or should I say proper way of setting up a heading for an operative report, order, spaces, tabs etc?  I know the doctor's way is always right but some doctors do not give enough information and some give too much.  Just wondering if you tab over diagnosis and align or place list under headings.  And spaces after each heading.

DATE OF PROCEDURE:

PREOPERATIVE DIAGNOSIS:

POSTOPERATIVE DIAGNOSIS:

PROCEDURE PERFORMED:

SURGEON:

ASSISTANT:

COMPLICATIONS:

ESTIMATED BLOOD LOSS:

FINDINGS:

PROCEDURE IN DETAIL: 

Has anyone heard anything about this CD?  I found it on ebay.  It has over 1000 multispecialty operative sample reports.  It's called: Softext Medical Transcription CD of Report Samples.   eBay Listing: 180302333955. 

Sounds like it could be a really good reference.  Just wondering.

MT

Here's what part of one of my Autotext entries looks like.  It has fields in it that I can just jump to by pressing F11.

OBJECTIVE: Height: {x} feet {x} inches.  Weight: {x}. Temperature: {x}.  Blood pressure: {x}.  Pulse: {x}.

On your menu bar in Word, just go to Insert-->Field-->then choose which you want.  Personally, I just choose the one labeled Comments but then I change the "formula" part (will show up in gray, this particular one says "COMMENTS   * MERGEFORMAT" in it) to just an X so that Word doesn't automatically insert something I don't need. It's like a placeholder for me.

I'm sure you can customize it even more but this is sufficient enough for me right now.

I have searched, but not really found one I am totally happy with.  If anyone has a good IC contract, please email me or let me know a link.

TIA!!!

Sunny

Can someone please post a link of where I can find a sample contract. Looking to strike out on my own - need a contract to present to docs.

Thanks

SPECIMEN:

1. Left breast biopsy
   
2. Apical axillary tissue
   
3. Contents of left radical mastectomy

GROSS DESCRIPTION:

Part #1 is labeled "left breast biopsy" and is received fresh after frozen section preparation. It consists of a single very firm nodularity measuring 3 cm in circular diameter and 1.5 cm in thickness, surrounded by adherent fibrofatty tissue. On section a pale gray, slightly mottled appearance is revealed. Numerous sections are submitted for permanent processing.

Part #2 is labeled "apical left axillary tissue" and is received fresh. It consists of two amorphous fibrofatty tissue masses without grossly discernible lymph nodes therein. Both pieces are rendered into numerous sections and submitted in their entirety for histology.

Part #3 is labeled "contents of left radical mastectomy" and is received fresh. It consists of a large ellipse of skin overlying breast tissue, the ellipse measuring 20 cm in length and 14 cm in height. A freshly sutured incision extends 3 cm directly lateral from the areola, corresponding to the closure for removal of part #1. Abundant amounts of fibrofatty connective tissue surround the entire breast, and the deep aspect includes an 8 cm length of pectoralis minor and a generous mass of overlying pectoralis major muscle. Incision from the deepest aspect of the specimen beneath the tumor mass reveals tumor extension grossly to within 0.5 cm of muscle. Sections are submitted according to the following code: DE - deep surgical resection margins; SU, LA, INF, ME - full thickness radial respectively; NI - nipple and subjacent tissue. Lymph nodes dissected free from axillary fibrofatty tissue from levels I, II, and III will be labeled accordingly.

MICROSCOPIC:

Sections of part #1 confirm frozen section diagnosis of infiltrating duct carcinoma. It is to be noted that the tumor cells show considerable pleomorphism, and mitotic figures are frequent (as many as 4 per high power field). Many foci of calcification are present within the tumor.

Part #2 consists of fibrofatty tissue and a single tiny lymph node free of disease.

Part #3 includes 18 lymph nodes, three from Level III, two from Level II and thirteen from Level I. All lymph nodes are free of disease with the exception of one Level I lymph node which contains several masses of metastatic carcinoma.

All sections taken radially from the superficial center of the resection site fail to include tumor, indicating the tumor to have originated deep within the breast parenchyma. Similarly, there is no malignancy in the nipple region, or in the lactiferous sinuses.

Sections of deep surgical margin demonstrate diffuse tumor infiltration of deep fatty tissues, however, there is no invasion of muscle. Total size of primary tumor is estimated to be 4 cm in greatest dimension.

DIAGNOSIS:

1. Infiltrating duct carcinoma, left breast.
2. Metastatic carcinoma, left axillary lymph node (1), Level I.
3. Lymph nodes, no pathologic diagnosis, left axilla, Level I (12), Level II (2), Level III (3).

I found this the below link quite helpful, particularly sample contract 2.

HTH

Best wishes.

Sample Contract
From Jennifer Martin, MT Monthly

This contract is made and entered into on _______(date) by _________(client) whose address is ____________ and _____________(your company name) whose address is ______________. In consideration of the mutual promises in this contract, the parties agree to abide by all the terms of this contact.

Contractor agrees to do the following: Medical transcription in accordance with client's documentation guidelines and forms. Services shall include: _______________________. Turnaround for transcription services shall be forty-eight (48) hours.

Pickup and delivery of the materials needed to complete this service will be made by the contractor, or his/her appointed courier, at the client's place of business at such a time agreed to by both parties. Contractor promises that the final product will be completed to the client's satisfaction.

For performing the work described above, client agrees to pay contractor the amount of ______ per line. It is agreed that sixty-five (65) characters constitutes a line.

Either party may terminate this agreement on not less than thirty (30) days' notice.

Confidentiality: As a contractor, it is my responsibility not to violate any confidence of the patient or their family through indiscriminate discussion pertaining to patients, their treatment, diagnosis, or progress. Erroneous and nonpublic information released by me shall result in legal liability. I understand and agree that all patient records and patient information are strictly confidential and will not make any disclosures.

Errors and Omissions Insurance: It is my policy that computer-authenticated or other artificial signatures generated by means other than the actual dictating physician's signature are not endorsed by me. Therefore, the doctors should proofread their transcription for document content, accuracy and quality control.

No changes shall be made in this agreement unless those changes are agreed to in writing by both contractor and client.

Transcriptionist (Contractor) - Subcontractor (other Transcriptionist or company) Contract

[Name of Contractor's Company]
[Contractor's Address]
[Contractor's Phone Number]

This completed document forms a contractual agreement between: ___________________________, referred herein as the Subcontractor, doing business at ______________________________________________, and the Contractor above so named.

The parties named herein desire a contractual business arrangement regarding the transcription of medical dictation and hereby agree:

1) Supplies provided to the Subcontractor by the Contractor that are a necessary requirement for the completion of work must be ordered by the Subcontractor from the Contractor or Contractor's client in a timely fashion such that the Subcontractor will not be without said necessities.

2) The Subcontractor is responsible for any supplies and equipment necessary to perform the contracted work. Furthermore, the Subcontractor is responsible for the upkeep of any machines or other equipment required to complete work and shall not let machines or equipment fall into disrepair, thereby affecting the Subcontractor's ability to perform work in the agreed manner and time.

3) The Subcontractor may only communicate with the Contractor's client in matters regarding the actual work of transcribing dictation for said client and may not communicate with said client regarding any matters concerning billing, pricing, or any other matter not pertaining to said work. In all communication with the Contractor's client, the Subcontractor shall identify themselves as agents of the Contractor and may not identify themselves as independent agents having their own business.

4) The Subcontractor agrees that patient and client confidentiality are of utmost importance. No work performed by the Subcontractor for the Contractor may be disposed of without first shredding said documents. The Subcontractor will set-up files and directories on computer(s) in such a way as to prevent unauthorized viewing, deleting, or copying. Said computer(s) will also be configured to prevent unauthorized use and will also employ security devices to prevent theft of said computer(s). No work shall be sent from the computer without it first being encrypted using a minimum of 128 bit encryption. No patient or client names will be stored by the Subcontractor in any form of database for use after termination of this contract. Regular back-ups of Contractor's Clients' work will be made in order not to forever lose the transcribed work.

5) Payment to the Subcontractor by the Contractor will be for completed work only. Payment will be made on a per-line basis at a rate of 0.__ per line with said line being 65 characters per line. Rush order payments will be the per-line rate plus 15% of the per-line rate. Any monetary penalties for late work imposed by the Contractor's client will be passed-on to the Subcontractor responsible for completion of that client's work, if the Subcontractor is responsible for said late work. The Subcontractor will have special labels on-hand at all times, of the type specified by the Contractor, should labels be required as part of completing work. The Subcontractor shall purchase these labels.

6) Invoices for payment for completed work must be submitted to the Contractor on the 14th (fourteenth) and 28th (twenty-eighth) day of each month. The Subcontractor must provide a separate invoice for each of the Contractor's clients with proof of work performed. The Contractor will pay the Subcontractor within 7 (seven) days of the Contractor being paid by the Contractor's client, except for weekends, holidays, and Acts of God.

7) Upon dissolution of this agreement, for whatever reason, machines, supplies, or equipment loaned to the Subcontractor by the Contractor, or the Contractor's client, must be returned to the Contractor or the replacement cost of said machines, supplies, or equipment will be deducted from outstanding monies owed by the Contractor to the Subcontractor. Should outstanding monies be insufficient to replace said unreturned machines, equipment, or supplies, the Contractor may still seek satisfaction under local laws and statutes of the Contractor's business domicile, or Subcontractor's business domicile, at the discretion of the Contractor.

8) At no time within 2 (two) years of termination of this contract may the Subcontractor approach or perform work for the Contractor's client in any form or manner, unless dealing with the Contractor as an agent. The Subcontractor may not accept any offer of work made by a Contractor's client, nor offer to provide services to a Contractor's client, either directly or by any other method or means, intended or unintended, that would disguise the client's identity, the Subcontractor's identity or would somehow obfuscate the relationship. No such relationship, including the Subcontractor working through or with another subcontractor, shall be allowed.

9) The contractor's name, logo, trade-mark or trade-marks, letterhead, and any other intellectual property of the Contractor shall remain exclusively as the Contractor's. The Subcontractor may only make use of these properties when acting as an agent of the Contractor. The Subcontractor may not act in such a way as to have others perceive them as actually being the Contractor and may not employ any device that would allow the Subcontractor to benefit from the Contractor's reputation.

10) The Contractor and Subcontractor must give written notice of at least 14 (fourteen) days of their desire to dissolve this contract. All outstanding work, finished work, loaned equipment, machines, or supplies, must be returned by the Subcontractor on the last day or prior to the last day of this notice. Within the life of the notice period, the Subcontractor is still bound to perform in accordance with this contract. Any substandard performance or inability to complete Contractor's clients' work by the Subcontractor in a timely fashion may result in the Contractor waving the notice period to save the Contractor's good business name. Any costs associated with premature dissolution of this contract in this regard may be deducted from the Subcontractor's final payment.

11) Breach of any part of this contract could result in the termination of this contract by the Contractor without notice to the Subcontractor. All normal clauses pertaining to dissolution of this agreement would then come into effect.

12) The Contractor reserves the right while under contract with the Subcontractor, and without formal notice, and without any explanation, to change or remove the Contractor's clients for whom the Subcontractor is performing work.

13) The Contractor cannot guarantee the quantity of work to be sent to the Subcontractor. The Subcontractor understands that the Subcontractor/Contractor relationship may depend in whole or in part on the relationship between the Contractor and the Contractor's client and understands fully therefore that loss of the client's work to the Contractor will be regarded by both parties as good and sufficient reason to thereby terminate the contract between the Contractor and Subcontractor.

The Subcontractor, ______________________________, agrees to honor and completely understands this contract, as confirmed with the Subcontractor's signature below.

}

____________________________________ }

Subcontractor or Authorized Person }

} Signed this ______ day of ______ in the year ______.

}

}

____________________________________ }

Contractor or Authorized Person }

}

Errors & Omissions Excepted

© 2000 ANSO Consulting Inc. & Medword Medical Transcription - www.medword.com

What I have done in the past when I wanted a raise is met the doctor halfway.  Keep in mind though that if you lower your rate, when will you ever get a raise?  :(

Transcriptionist-Physcian (or other Client) Contract

[Name of Transcriptionist's Company]
[Transcriptionist's Address]
[Transcriptionist's Phone Number]

This completed document forms a contractual agreement between: ___________________________, referred herein as the Transcriptionist, doing business at ___________________, and ____________________ herein referred to as the Client, doing business at _________________________.

The parties named herein desire a contractual business arrangement regarding the transcription of medical dictation and hereby agree:

1) Supplies provided to the Transcriptionist by the Client that are a necessary requirement for the completion of work must be ordered by the Transcriptionist from the Client in a timely fashion such that the Transcriptionist will not be without said necessities. If not supplied by the Client, the Transcriptionist is responsible for any supplies and equipment necessary to perform the contracted work.

2) The Transcriptionist agrees that patient and client confidentiality are of utmost importance. No work performed by the Transcriptionist for the Client will be disposed of without first shredding said documents. The Transcriptionist will set-up files and directories on computer(s) in such a way as to prevent unauthorized viewing, deleting, or copying. Said computer(s) will also be configured to prevent unauthorized use and will also employ security devices to prevent theft of said computer(s). No work shall be sent from the computer without it first being encrypted using a minimum of 128 bit encryption. No patient or client names will be stored by the Transcriptionist in any form of database for use after termination of this contract. Regular back-ups of Client work will be made in order not to forever lose the transcribed work.

3) Payment to the Transcriptionist by the Client will be for completed work only. Payment will be made on a per-line basis at a rate of 0.__ per line with said line being 65 characters per line. Rush order payments will be the per-line rate plus 15% of the per-line rate.

4) Invoices for payment for completed work will be submitted to the Client on the 14th (fourteenth) and 28th (twenty-eighth) day of each month with the Client providing payment within 5 (five) days of submission of said invoice.

5) Upon dissolution of this agreement, for whatever reason, machines, supplies, or equipment loaned to the Transcriptionist by the Client will be returned to the Client or the replacement cost of said machines, supplies, or equipment will be deducted from outstanding monies owed by the Client to the Transcriptionist. Should outstanding monies be insufficient to replace said unreturned machines, equipment, or supplies, the Client may still seek satisfaction by legal means.

6) The Client's name, logo, trade-mark or trade-marks, letterhead, and any other intellectual property of the Client shall remain exclusively as the Client's. The Transcriptionist may only make use of these properties when performing work for the Client.

7) The Client and Transcriptionist must give written notice of at least 14 (fourteen) days of their desire to dissolve this contract. All outstanding work, finished work, loaned equipment, machines, or supplies, will be returned by the Transcriptionist on the last day or prior to the last day of notice. Within the life of the notice period, the Transcriptionist will perform in accordance with this contract. Any substandard performance or inability to complete the Client's work by the Transcriptionist in a timely fashion may result in the Client waving the notice period. Any costs associated with premature dissolution of this contract in this regard, such as hiring another transcriptionist on short notice or at a higher rate, may be deducted from the Transcriptionist's final payment.

8) Breach of any part of this contract by either party could result in the termination of this contract by the offended party. All normal clauses pertaining to dissolution of this agreement would then come into effect.

The Client, ______________________________, agrees to honor and completely understands this contract, as confirmed with the Client's signature below.

}

____________________________________ }

Client or Authorized Person }

} Signed this ______ day of ______ in the year ______.

}

}

____________________________________ }

Transcriptionist or Authorized Person }

}

Errors & Omissions Excepted

I have one office/account of three OB-GYN's that I provide MT service for and am in need of a sample contract for them, between myself and their office. Is there any place I can locate one or does anyone have one that they may be willing to share???

Thanks so very much.