Dental Surgery Medical Transcription Procedure Sample Reports


DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Dental infection.

POSTOPERATIVE DIAGNOSIS:  Dental infection. 

PROCEDURES PERFORMED:
1.  Dental radiographs.
2.  Scaling and root planing.
3.  Extractions.

SURGEON:  John Doe, DMD

DESCRIPTION OF PROCEDURE:  The patient was taken to the OR after being given IM ketamine and IV was started on the left hand. The patient was intubated through the left naris. The patient was maintained on nitrous oxide, oxygen and sevoflurane. Sterile drapes were placed in the usual manner. The patient's oropharynx and mouth were irrigated and thoroughly suctioned and a thin moist throat pack was placed. Full mouth set of dental x-rays were taken revealing no interproximal decay, but slight to moderate periodontal disease. Fractures were noted on tooth numbers 10 and 26. A thorough periodontal curettage was undertaken to eliminate calculus and debris that accumulate around the gingival crevice. Prophylaxis with fluoride treatment was given. Teeth numbers 10 and 26 were extracted. The apical root portions were left, as they appeared to be resorbing into the bone. Two 4-0 gut sutures were placed. Hemorrhage was easily controlled. Estimated blood loss was minimal. The throat pack was removed. The patient was extubated in the operating room and taken to the recovery room. The patient's condition was good during the recovery. The prognosis for the remaining dentition is guarded. The patient will eventually be in need of full mouth extractions. The patient is to be discharged with instructions including activity, diet and medications. The patient will be seen in one week for postoperative evaluation.

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DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Dental infection.

POSTOPERATIVE DIAGNOSIS:  Dental infection.

PROCEDURE PERFORMED:  Crowns, pulpotomies, fillings, extractions.

SURGEON:  John Doe, DMD

DESCRIPTION OF PROCEDURE:  The patient was brought into the operating room and placed in the supine position. After satisfactory level of general anesthesia had been administered by nasotracheal intubation, a 4 x 4 gauze throat pack was placed and the following dental procedures were then carried out based upon a thorough oral examination and radiographs.  The upper left first and second primary molars, the lower left second primary molar and the lower right first and second primary molars were excavated of caries and prepared to receive stainless steel crowns. Prior to crown placement, a pulpotomy was performed on the upper left second primary molar, the lower left second primary molar and the lower right first primary molar. Crowns were then closely fitted to these teeth and cemented with FujiCEM cement. All four first permanent molars, the upper left primary canine and the lower right primary canine were excavated of caries and restored with light-bonded Z100. The upper primary central and laterals, the upper right first and second primary molars, both lower primary laterals, and the lower left first primary molar were then extracted by means of elevator and forceps. Gelfoam was placed in the sockets and tissue was closely approximated and sutured with 3-0 chromic suture. Prophylaxis with topical fluoride was then applied. The mouth was suctioned, throat pack removed and the patient then taken to the recovery room in satisfactory condition having tolerated the procedure well

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PREOPERATIVE DIAGNOSIS:  Severe dental disease.

POSTOPERATIVE DIAGNOSIS:  Severe dental disease.

PROCEDURE PERFORMED:  Full mouth dental rehabilitation.

SURGEON:  John Doe, DMD

ANESTHESIA:  General.

DESCRIPTION OF PROCEDURE:  The patient was transported to the operating room and placed on the operating table in the supine position.  General anesthesia was begun in the usual manner via IV sedation and nasal intubation.  The patient was draped in the usual manner.  The oropharynx was examined and suctioned free of debris.  A moist oropharyngeal pack was placed.  A complete dental examination was performed.  Oral radiographs were reviewed.  Treatment plan was then formulated.  A dental prophylaxis was performed and the following restorations were completed.  Tooth #C, pulpectomy; Tooth #B, stainless steel crown; Tooth #K, distolingual resin; Tooth #L, pulpectomy; Tooth #I, stainless steel crown; Tooth #H, pulpectomy, Tooth #K, stainless steel crown; Tooth #I, pulpectomy; Tooth #L, stainless steel crown and Tooth #S disto-occlusal resin.  The following teeth were then extracted without complication.  Tooth #A; it was deemed to be necrotic and nonrestorable.  Tooth #J; the tooth was nonrestorable due to gross decay and insufficient tooth structure, and Tooth #T was grossly broken down and was basically left to root remnants.  The mouth was examined and suctioned free of debris.  Topical fluoride was applied to all teeth and the oropharyngeal pack was removed.  Blood loss was deemed to be minimal.  The patient was extubated and transported to the postoperative recovery room in a drowsy, but stable condition.

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DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Severe dental caries and infection.

POSTOPERATIVE DIAGNOSIS:  Severe dental caries and infection.

PROCEDURES PERFORMED:  Dental restorations, extractions, impressions.

SURGEON:  John Doe, DMD

DESCRIPTION OF PROCEDURE:  The patient was taken to the OR, induced with nitrous oxide, oxygen, sevoflurane. An IV was started in the left hand. The patient was intubated through the right naris. The patient was maintained on nitrous oxide, oxygen, sevoflurane. Sterile drapes were placed in the usual manner. The patient's oropharynx and mouth were irrigated, thoroughly suctioned and a thin, moist throat pack was placed. Tooth number 14 was restored with an OL composite restoration. Tooth numbers B and S were restored with formocresol pulpotomies and stainless steel crowns cemented with Ketac. Tooth number J was restored with an MOL composite restoration. Tooth number L was restored with an OL composite restoration. Tooth number A was nonrestorable; it was extracted. Gelfoam was placed in the extraction sockets. One 4-0 gut suture was placed. Tooth numbers D and G were also extracted without difficulty. A single tooth gingivectomy was performed to aid the eruption of tooth 3. Tooth number B was fitted with a stainless steel band and impression was taken for a reverse band. Hemorrhage was easily controlled. Estimated blood loss was minimal. Throat pack was removed. The patient was extubated in the operating room and taken to the recovery room.

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DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Dental caries.

POSTOPERATIVE DIAGNOSIS:  Dental caries.

PROCEDURE PERFORMED:  Full mouth rehabilitation.

SURGEON:  John Doe, DMD

DESCRIPTION OF PROCEDURE:  The patient was sedated with Versed and taken to the operating room. General anesthesia was induced with sevoflurane and a mask. IV was started in the left hand. Three x-rays were taken, two bite wings and one occlusal. A saline throat pack was placed along with 1 carpule of 2% Xylocaine, 1:100,000 epinephrine given. A mouth prop was used and the following restorations were performed.  Tooth C received an OL composite with Venus shade A1. Tooth #M received an occlusal composite with Venus shade A1. Ionoseal liner was placed.  Tooth #T received occlusal composite with Venus A1. Tooth #A and I received sealants with Clinpro. Tooth #O and P were extracted with Gelfoam placed. Tooth #D and tooth #G received composite strip crowns with TPH shade A1. Tooth #N received an Ionoseal liner and stainless steel crown cemented with Ketac cement, crown size E3. Tooth #K and T also received stainless steel crowns cemented with Ketac cement. Tooth #P received an Ionoseal liner, stainless steel crowns cemented with Ketac cement and crown size E3. Tooth #T crown size E3. The oral cavity was thoroughly irrigated, suctioned and inspected for debris. The moist saline throat pack was removed and the face cleansed with water.





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