tag:blogger.com,1999:blog-7030189342403602562026-11-03T18:48:01.891-08:00Medical Transcription Sample ReportsOver 500 Medical Transcription Sample Reports For Medical Transcriptionists!!Unknownnoreply@blogger.comBlogger628125tag:blogger.com,1999:blog-703018934240360256.post-47215007144597462572026-11-03T18:48:01.890-08:002026-11-03T18:48:01.891-08:00Transmetatarsal Amputation Transcription Sample ReportDATE OF OPERATION: MM/DD/YYYYPREOPERATIVE DIAGNOSIS: Nonhealing left first and second toe amputation with third toe gangrene.POSTOPERATIVE DIAGNOSIS: Nonhealing left first and second toe amputation with third toe gangrene.OPERATION PERFORMED: Completion left transmetatarsal amputation.SURGEON: John Doe, MDANESTHESIA: General endotracheal.INDICATIONS FOR Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-27469016135282981332026-11-03T18:46:51.729-08:002026-11-03T18:46:51.730-08:00Ophthalmology SOAP Note Sample ReportSUBJECTIVE: The patient was seen in followup today. She is a pleasant (XX)-year-old with a history of moderate dry macular degeneration. The patient reports some slight blurring of vision at near.OBJECTIVE: Visual acuity, uncorrected, is 20/30-2 OD, 20/50 pinhole, 20/40 OS. Intraocular pressure is 19 mmHg OU. Anterior segment examination shows 2+ NS, OD and a PCIOL OS. Dilated Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-77710715647276087212026-11-03T18:45:14.398-08:002026-11-03T18:45:14.398-08:00Dilation and Curettage D&C Operative Transcription Sample ReportDATE OF OPERATION: MM/DD/YYYYPREOPERATIVE DIAGNOSIS: Incomplete spontaneous abortion with vaginal bleeding.POSTOPERATIVE DIAGNOSIS: Incomplete spontaneous abortion with vaginal bleeding.OPERATION PERFORMED: Dilation and curettage.SURGEON: John Doe, MDASSISTANTS: None.ANESTHESIA: General endotracheal anesthesia.ANESTHESIOLOGIST: Jane Doe, Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-50768504911571095422026-11-03T18:44:08.102-08:002026-11-03T18:44:08.103-08:00Cesarean Section Dictation Transcription Sample ReportDATE OF OPERATION: MM/DD/YYYYPREOPERATIVE DIAGNOSES:1. Intrauterine pregnancy at 40 weeks.2. Frank breech position.POSTOPERATIVE DIAGNOSES:1. Intrauterine pregnancy at 40 weeks.2. Frank breech position.OPERATION PERFORMED: Primary low transverse cesarean section with two-layer closure.SURGEON: John Doe, MDANESTHESIA: Spinal anesthesia.COMPLICATIONS:Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-69402982039151891582026-11-03T18:43:05.419-08:002026-11-03T18:43:05.419-08:00Bronchoscopy with Bronchoalveolar Lavage Sample ReportDATE OF PROCEDURE: MM/DD/YYYYPREOPERATIVE DIAGNOSES:1. Respiratory failure.2. Possible pneumonia.PROCEDURE PERFORMED: Bronchoscopy with bronchoalveolar lavage.SURGEON: John Doe, MDANESTHESIA: IV sedation.ESTIMATED BLOOD LOSS: Zero.SPECIMENS: Left and right bronchoalveolar lavage for microbiology.COMPLICATIONS: None.INDICATIONS FOR PROCEDURE:&Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-31116657908553249812026-11-03T18:41:43.628-08:002026-11-03T18:41:43.628-08:00Above Knee Amputation Operative Sample Report DATE OF OPERATION: MM/DD/YYYYPREOPERATIVE DIAGNOSIS: Severe ischemia, left lower extremity.POSTOPERATIVE DIAGNOSIS: Severe ischemia, left lower extremity.OPERATION PERFORMED: Left above knee amputation.SURGEON: John Doe, MDANESTHESIA: General anesthesia.DESCRIPTION OF OPERATION: The patient was brought to the operating room and was placed in the Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-34559155751615965262026-11-03T18:39:32.903-08:002026-11-03T18:39:32.903-08:00Marsupialization of Bartholin Gland Abscess Sample Report DATE OF OPERATION: MM/DD/YYYYPREOPERATIVE DIAGNOSIS: Left Bartholin gland abscess.POSTOPERATIVE DIAGNOSIS: Left Bartholin gland abscess.OPERATION PERFORMED: Marsupialization of left Bartholin gland abscess.SURGEON: John Doe, MDASSISTANT: Jane Doe, MDANESTHESIA: General.ESTIMATED BLOOD LOSS: Negligible.COMPLICATIONS: None.INDICATIONS FOR Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-89197138769606438482026-11-03T18:37:42.376-08:002026-11-03T18:37:42.376-08:00Laparoscopic Salpingectomy Sample ReportLAPAROSCOPIC SALPINGECTOMY PROCEDURE SAMPLE REPORTDATE OF OPERATION: MM/DD/YYYYPREOPERATIVE DIAGNOSIS: Left ectopic pregnancy and cerclage in place.POSTOPERATIVE DIAGNOSIS: Left ectopic pregnancy and cerclage in place.OPERATION PERFORMED: Laparoscopic left salpingectomy and cervical exam under anesthesia.SURGEON: John Doe, MDASSISTANT: None.ANESTHESIA: General endotracheal.ESTIMATED BLOOD LOSS: Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-4600395177892182682026-11-03T18:35:23.966-08:002026-11-03T18:35:23.967-08:00Below Knee Amputation Operative Sample Report DATE OF OPERATION: MM/DD/YYYYPREOPERATIVE DIAGNOSIS: Ischemic left foot.POSTOPERATIVE DIAGNOSIS: Ischemic left foot.OPERATION PERFORMED: Left below-the-knee amputation.SURGEON: John Doe, MDASSISTANT: Jane Doe, MDANESTHESIA: General, orotracheal intubation plus epidural.DESCRIPTION OF OPERATION: The patient was placed supine. The left lower Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-8326403203501507852026-11-03T18:32:24.406-08:002026-11-03T18:32:24.406-08:00Loop Electrosurgical Excision Procedure Sample Report DATE OF OPERATION: MM/DD/YYYYPREOPERATIVE DIAGNOSIS: Moderate cervical dysplasia.POSTOPERATIVE DIAGNOSIS: Moderate cervical dysplasia.OPERATION PERFORMED: Loop electrosurgical excision procedure conization of the cervix.SURGEON: John Doe, MDANESTHESIA: General by LMA.ANESTHESIOLOGIST: Jane Doe, MDCOUNTS: Sponge and needle counts were announced as correct x2.ESTIMATED BLOOD LOSS: 10 Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-71934960556597471082024-03-05T00:53:00.000-08:002024-03-05T00:53:22.756-08:00Delivery Note - Normal Spontaneous Vaginal Delivery Sample DATE OF DELIVERY: MM/DD/YYYY PREDELIVERY DIAGNOSES:1. Gravida 1, para 0.2. Singleton intrauterine pregnancy at 41 and 2/7 weeks' gestation.3. Prolonged rupture of membranes.4. Meconium-stained amniotic fluid.5. Active labor. POSTDELIVERY DIAGNOSIS: Normal spontaneous vaginal delivery of a viable female in the left occipitoanterior positionUnknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-29073607138686016692024-03-04T21:30:00.000-08:002024-03-04T21:30:38.688-08:00Brain MRI Medical Transcription SampleHISTORY: Asymmetric hearing loss.MRI of the IACs was taken with and without contrast, thin sections, in coronal and axial images. Images through the whole head were also performed, both pre and postcontrast.There is no evidence of an enhancing schwannoma or acoustic neuroma in the area of either internal auditory canal or the cerebellopontine angle. We do, however, see significant left Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-77315383227282933472024-03-04T21:21:00.000-08:002024-03-04T21:21:40.343-08:00Neuropsychological Evaluation Medical Transcription Sample Neuropsychological Evaluation Medical Transcription SampleREASON FOR REFERRAL: The patient is a (XX)-year-old male who returns at this time for yearly neuropsychological evaluation. He has been diagnosed with mild cognitive impairment and evaluation at this time was recommended to determine the presence of any improvement following implementation of CPAP for sleep apnea.TESTS PERFORMED: Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-55770025810178959812024-03-04T20:36:00.000-08:002024-03-04T20:36:17.537-08:00Laparoscopic Low Anterior Resection Operative Sample Report PREOPERATIVE DIAGNOSIS: Rectal cancer.POSTOPERATIVE DIAGNOSES:1. Rectal cancer.2. Umbilical hernia.OPERATIONS PERFORMED:1. Laparoscopic low anterior resection.2. Laparoscopic mobilization of splenic flexure.3. Umbilical hernia repair.SURGEON: John Doe, MDASSISTANT: Jane Doe, MDANESTHESIA: General endotracheal.OPERATIVE FINDINGS:1. Rectal cancer.2. Umbilical hernia.3. Obesity.SPECIMENS: Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-24533836311951789862024-03-04T20:34:00.000-08:002024-03-04T20:34:02.413-08:00Subarachnoid Hemorrhage Medical Transcription Sample Report DIAGNOSIS: Subarachnoid hemorrhage.CHIEF COMPLAINT: Headache.HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old woman in her usual state of health until yesterday when she apparently fell. She was lying on the couch when someone knocked at her door and she arose quickly to answer the door and apparently lost her balance and became lightheaded. The next thing she remembers, she Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-89160705768877276452021-07-17T21:44:00.000-07:002021-07-17T21:44:09.666-07:00Ulcers of Leg SOAP Note Medical Transcription Sample ReportSUBJECTIVE: This is a (XX)-year-old Hispanic female with a past medical history as mentioned in the previous visit, who came for a followup for the ulcers in the left leg. Apparently, the left ulcer has still not completely healed but with erythema and less induration. There is some purulent discharge noted. The leg edema is markedly improved with diuretics. The patient Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-49998357910210613122021-07-11T21:44:00.000-07:002021-07-11T21:44:46.304-07:00Ingrown Toenail Progress Note Transcription Sample ReportHISTORY OF PRESENT ILLNESS: The patient comes in with 2 concerns. Primarily, he has noted an infection on his right great toe. For about 2 days, he noticed it was a little bit sore and red and it increased over the past 2 days and it woke him up throbbing last night.He has not had any fevers or chills. He has been cleaning it with alcohol and peroxide and squeezing small amounts of pus fromUnknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-10386081656318350212020-05-12T07:39:00.001-07:002020-05-12T07:42:36.536-07:00Colorectal Surgery SOAP Note Transcription Sample Report
DATE OF SERVICE: MM/DD/YYYY
SUBJECTIVE: The patient is here for a long office visit. He was recently discharged from an outside clinic where he had been admitted after he had a bowel obstruction. He had recurrent strictures of ileum from Crohn's disease.
He is followed by Dr. John Doe. He finally underwent a resection by Dr. Jane Doe, 2-3 feet of terminal ileum, which was Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-81805587042832293812020-05-07T22:09:00.000-07:002020-05-07T22:09:03.453-07:00Bloody Diarrhea Transcription Consultation Sample Report
REASON FOR CONSULTATION: Bloody diarrhea for about 10 days.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who presented to the emergency room with 10 days of bloody diarrhea. She had been given Augmentin 875 mg for a total of 10-day course for presumed infection of her foot and pain about 2-1/2 weeks ago.
She had no problems with GI symptoms until 7 days Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-65405218908364529802016-07-19T19:11:00.001-07:002017-09-11T04:09:15.064-07:00Closed Base Wedge Osteotomy Operative Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Painful bunion deformity of the left foot.
POSTOPERATIVE DIAGNOSIS: Painful bunion deformity of the left foot.
OPERATION PERFORMED:
1. Closed base wedge osteotomy of the first metatarsal of the left foot with screw fixation.
2. Reverdin-Green osteotomy of the first metatarsal of the left foot with screw Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-45591091773719099752016-05-27T20:34:00.000-07:002016-05-27T20:46:29.388-07:00Submuscular Ulnar Nerve Transposition Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left ulnar neuropathy at the elbow.
2. Left ulnar neuropathy at the wrist.
POSTOPERATIVE DIAGNOSES:
1. Left ulnar neuropathy at the elbow.
2. Left ulnar neuropathy at the wrist.
OPERATION PERFORMED:
1. Left submuscular ulnar nerve transposition.
2. Left ulnar tunnel release.
SURGEON: JohnUnknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-73961352833350745152016-05-02T07:11:00.000-07:002020-02-21T20:04:40.883-08:00Management of Kidney Transplant Sample Report
DATE OF VISIT: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old lady who received a living-related kidney transplant four years ago in the setting of end-stage renal disease secondary to diabetic nephropathy. She is coming in here for reevaluation and management. She lives mainly overseas and she gets her blood work every three months there, and we Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-70450649078298378422016-04-30T23:47:00.000-07:002017-09-11T05:54:19.883-07:00Prostate Adenocarcinoma Consult Sample Report
DATE OF CONSULTATION: MM/DD/YYYY
REASON FOR CONSULTATION: Prostate adenocarcinoma.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old who underwent prostate biopsies for a rising PSA. Biopsies were negative for malignancy. His PSA was followed and ultimately rose to 7.6 last year. This prompted a second round of prostate biopsies showing one core Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-62750356325937409562016-04-30T23:05:00.002-07:002020-02-21T20:07:32.297-08:00Bunionectomy with Osteotomy Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Hallux abductovalgus deformity on the right lower extremity.
POSTOPERATIVE DIAGNOSIS: Hallux abductovalgus deformity on the right lower extremity.
OPERATION PERFORMED: Bunionectomy with osteotomy and internal fixation of the right foot.
SURGEON: John Doe, MD
ANESTHESIA: Local with IV sedation.
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-27338314012652105622016-04-28T22:22:00.000-07:002024-03-05T01:00:48.377-08:00Tibial Sesamoid Excision Operative Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Chronic sesamoiditis of the left foot with elongated first metatarsal and contracted left hallux.
POSTOPERATIVE DIAGNOSIS: Chronic sesamoiditis of the left foot with elongated first metatarsal and contracted left hallux with degenerative changes of the sesamoid apparatus of the left foot.
OPERATION PERFORMED:
1. Unknownnoreply@blogger.com