tag:blogger.com,1999:blog-7030189342403602562025-10-08T11:22:48.177-07:00Medical Transcription Sample ReportsOver 500 Medical Transcription Sample Reports For Medical Transcriptionists!!Unknownnoreply@blogger.comBlogger618125tag: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.comtag:blogger.com,1999:blog-703018934240360256.post-14900050330833250272016-04-28T21:33:00.000-07:002020-02-24T21:33:16.699-08:00Cardiomyopathy Discharge Summary Sample Report
DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
FINAL DIAGNOSES:
1. Cardiomyopathy.
2. Atrial fibrillation, new onset, with rapid ventricular response.
3. Congestive heart failure.
PROCEDURES PERFORMED:
1. Left heart catheterization.
2. Coronary angiography.
3. Left ventriculogram.
CONSULTANT: John Doe, MD
HISTORY OF PRESENT Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-10999784739738780022016-04-28T05:57:00.000-07:002025-10-07T21:06:47.877-07:00Shoulder Arthroscopic Decompression Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Right shoulder impingement syndrome.
2. Right shoulder acromioclavicular joint arthritis.
3. Right shoulder rotator cuff tear.
POSTOPERATIVE DIAGNOSES:
1. Right shoulder impingement syndrome.
2. Right shoulder acromioclavicular joint arthritis.
3. Right shoulder rotator cuff tear.
OPERATION Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-63291710285848947812016-03-28T04:23:00.002-07:002020-02-24T21:34:34.333-08:00Scalp Injury ER Medical Transcription Sample Report
DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Scalp injury.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who apparently was at a party tonight when he slipped on something on the floor, fell down, hit the back of his head, noted some blood, and came in complaining of some mild sharp scalp pain since.
The patient denies any loss of consciousness. The Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-10755702817488758582016-03-27T06:39:00.000-07:002020-02-24T12:00:15.571-08:00Pancreatic Cancer Consultation Sample Report
DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Pancreatic cancer.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old lady whom we have been following for metastatic pancreatic cancer. We saw the patient last in the office in August, and we felt that her clinical condition was deteriorating and she was not strong Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-58662563873181174872016-03-22T04:08:00.003-07:002020-02-21T20:06:34.027-08:00Femur Fracture Intramedullary Nailing Operative Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Right femur fracture.
2. Right patella fracture.
3. Left base of fifth metacarpal fracture.
POSTOPERATIVE DIAGNOSES:
1. Right femur fracture.
2. Right patella fracture.
3. Left base of fifth metacarpal fracture.
OPERATIONS PERFORMED:
1. Intramedullary nailing, right femur fracture.
2. &Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-3512074678857535422016-02-15T19:27:00.002-08:002017-09-11T05:58:16.540-07:00Arthroscopic Subacromial Decompression Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right rotator cuff tear.
POSTOPERATIVE DIAGNOSES:
1. Right rotator cuff tear, subscapularis and supraspinatus.
2. Right labral tear.
OPERATION PERFORMED:
1. Right arthroscopic subacromial decompression.
2. Right arthroscopic extensive debridement to include the labrum, subscapularis and supraspinatus Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-9725182861890609672016-02-12T02:19:00.000-08:002020-02-21T20:06:52.588-08:00Knee Arthrotomy Transcribed Operative Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Gunshot wound to right knee.
2. Right patellar fracture.
3. Right femoral lateral condyle fracture.
POSTOPERATIVE DIAGNOSES:
1. Gunshot wound to right knee.
2. Comminuted fracture of lateral facet of patella.
3. Fracture of lateral condyle, femur.
4. Retained bullet fragments in knee joint.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-61905540376526307622015-12-29T08:35:00.002-08:002017-09-11T05:59:50.281-07:00Inferior Turbinate Submucosal Reduction Operative Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Inferior turbinate hypertrophy.
2. Nasal obstruction.
POSTOPERATIVE DIAGNOSES:
1. Inferior turbinate hypertrophy.
2. Nasal obstruction.
OPERATION PERFORMED: Bilateral inferior turbinate submucosal reduction.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General.
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-28217043586813920082015-12-27T23:04:00.000-08:002015-12-27T23:04:05.070-08:00Breast Needle Localized Lumpectomy Operative Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right breast cancer.
POSTOPERATIVE DIAGNOSIS: Right breast cancer.
OPERATION PERFORMED:
1. Right breast needle-localized lumpectomy.
2. Sentinel node biopsy.
3. Axillary node dissection.
SURGEON: John Doe, MD
ANESTHESIA: General.
COMPLICATIONS: None.
INDICATION FOR OPERATION: Unknownnoreply@blogger.comtag:blogger.com,1999:blog-703018934240360256.post-51463954122476063002015-12-19T09:14:00.000-08:002015-12-19T09:18:09.307-08:00Closed Reduction of Vertebral Fracture Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. C5-6 facet fracture.
2. Left C6 radiculitis.
POSTOPERATIVE DIAGNOSES:
1. C5-6 facet fracture.
2. Left C6 radiculitis.
OPERATIONS PERFORMED:
1. Attempted closed reduction of vertebral fracture and subluxation with traction.
2. Subsequent open reduction and treatment of vertebralUnknownnoreply@blogger.com