DENTAL SURGERY MEDICAL TRANSCRIPTION SAMPLE REPORT
PREOPERATIVE DIAGNOSIS: Severe dental caries and infection.
POSTOPERATIVE DIAGNOSIS: Severe dental caries and infection.
PROCEDURE PERFORMED: Dental restorations, extractions and impressions.
SURGEON: John Doe, DMD
ASSISTANT: Jane Doe
DESCRIPTION OF PROCEDURE: The patient was taken to the OR and induced with nitrous oxide oxygen and sevoflurane. An IV was started in the left hand. The patient was intubated through the right naris and 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. A thin moist throat pack was placed.
Teeth #3, 14 and 19 were restored with pit and fissure sealants. Tooth #30 was restored with an OBcomposite restoration. Teeth #A and J were restored with OL composite restorations. Teeth #K and T were restored with OBcomposite restorations. Teeth #B and L were restored with stainless steel crown cemented with Ketac. Tooth #S was restored with a formocresol pulpotomy and a stainless steel crown was cemented with Ketac.
Tooth #I was restored with an occlusal composite restoration. Teeth #M, Q and R were extracted without difficulty. Gelfoam was placed in the extraction sockets. Two 4-0 gut sutures were placed. Teeth #K and T were fitted with stainless steel bands and impressions were taken for fabrication of a lingual arch holding appliance. 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. The patient’s condition was good during the recovery period. The prognosis for retention of the remaining dentition is good. The patient is to be discharged with instructions including activity, diet, medications; diet being liquid, may proceed with soft diet at dinner if the patient tolerates. The patient is to be seen in my office in one week for postoperative evaluation.
