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Medical Specialty
Allergy / Immunology
Autopsy
Bariatrics
Cardiovascular / Pulmonary
Chiropractic
Consult - History and Phy.
Cosmetic / Plastic Surgery
Dentistry
Dermatology
Diets and Nutritions
Discharge Summary
Emergency Room Reports
Endocrinology
ENT - Otolaryngology
Gastroenterology
General Medicine
Hematology - Oncology
Hospice - Palliative Care
IME-QME-Work Comp etc.
Lab Medicine - Pathology
Letters
Nephrology
Neurology
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Obstetrics / Gynecology
Office Notes
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Pain Management
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Physical Medicine - Rehab
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Rheumatology
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SOAP / Chart / Progress Notes
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Surgery
Urology
SOAP / Chart / Progress Notes - Medical Reports
Acne - SOAP
Acquired Hypothyroidism Followup
Allergic Rhinitis
Anemia & Leukemia Followup
Aplastic Anemia Followup
Asperger Disorder
Atrial Fibrillation - SOAP
Atrial Flutter - Progress Note
Bell's Palsy
Breast Cancer Followup
Breast Cancer Followup - 1
Breast Radiation Therapy Followup
Bunions and Calluses
CAD - 6-Month Followup
Carbohydrate Counting
Cardiology Progress Note
Cardiology Progress Note - 1
Care Conference With Family
Cataract - Second Opinion
Cataract Extraction Followup
Cervical Spinal Stenosis
Cervicalgia
Chest Pain & Respiratory Insufficiency
Chiropractic Progress Note
Chronic Kidney Disease Followup
Chronic Kidney Disease Followup - 1
Chronic Medical Conditions - Followup
Circumcision Followup
Clostridium Difficile Colitis Followup
COPD & Pneumonia - SOAP
Craniopharyngioma - Postop
CyberKnife Treatment - Followup
D&C & Hysteroscopy Followup
Dermatitis - SOAP
Deviated Septum Repair - Followup
Diabetes Mellitus - SOAP Note - 1
Diabetes Mellitus - SOAP Note - 2
Diabetes Mellitus Followup
Diabetic Foot Care
Dietary Consult - 1
Dietary Consult - 2
Dietary Consult - 3
Dietary Consult - 4
Dietary Consult - Diabetes - 1
Dietary Consult - Diabetes - 2
Dietary Consult - Gestational Diabetes
Dietary Consult - Hyperlipidemia
Dietary Consult - Weight Reduction
Down's syndrome
E. Coli UTI - Followup
Elevated PSA - Chart Note
Endometrial Cancer Followup
Erectile Dysfunction - Followup
Evaluation of Allergies
Facial Rhytids
Fifth Disease - SOAP
Followup Screw Fixation
Foot Lesions
Foot Pain - SOAP
Foreskin - Followup
Fundoplication & Gastrostomy Followup
Gastric Bypass - Preop Eval
Gen Med Progress Note
Gen Med Progress Note - 1
Gen Med Progress Note - 10
Gen Med Progress Note - 11
Gen Med Progress Note - 12
Gen Med Progress Note - 13
Gen Med Progress Note - 2
Gen Med Progress Note - 3
Gen Med Progress Note - 4
Gen Med Progress Note - 5
Gen Med Progress Note - 6
Gen Med Progress Note - 7
Gen Med Progress Note - 8
Gen Med Progress Note - 9
Gen Med SOAP
Gen Med SOAP - 1
Gen Med SOAP - 10
Gen Med SOAP - 11
Gen Med SOAP - 2
Gen Med SOAP - 3
Gen Med SOAP - 4
Gen Med SOAP - 5
Gen Med SOAP - 6
Gen Med SOAP - 7
Gen Med SOAP - 8
Gen Med SOAP - 9
Hand Discomfort - Followup
HIV Followup
HIV Followup - 1
Hypertension - Progress Note
Infected Toenails
Ischemic Cardiac Disease - Progress Note
Laminectomy & Foraminotomy Followup
Lap Band Adjustment
Leg Pain - Progress Note
Leg Pain & Bone Pain
Lobectomy - Followup
Low Back Pain from Exercise
Lung Biopsy Discussion
Lung Cancer Followup
Mantle Cell Lymphoma
Melena - ICU Followup
Mesothelioma - Chart Note
MGUS Followup
Multiple Medical Problems
Multiple Progress Notes
Nephrolithiasis - Progress Note
Neurologic Examination
Non-Hodgkin lymphoma Followup
Obesity Hypoventilation Syndrome
Ophthalmology Progress Note - 1
Ophthalmology Progress Note - 2
ORIF - Followup
ORIF Facial Fractures - Followup
Osteoarthritis - Progress Note
Overactive Bladder
PAF - 6-Month Followup
Pain Management Progress Note
Physical Therapy - Outpatient Rehab
Plantar Fasciitis
Podiatry - Progress Note
Poison Ivy - SOAP
Polycythemia Rubra Vera
Polycythemia Vera Followup
Possible Spider Bite
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Posttransplant Lymphoproliferative Disorder
Progress Note - Iron Deficiency Anemia
Progress Note - Liver Cirrhosis
Progress Note - Supraglottitis
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Prostate Adenocarcinoma - 2
Prostate Adenocarcinoma - 3
Prostate Adenocarcinoma - 4
Prostate Fossa Irradiation - Followup
Prostatitis - Recheck
Pulmonary - Followup Note
Pulmonary Medicine Clinic Followup
Q-Fever Endocarditis
Recheck of ADHD Meds
Refractory Hypertension - Followup
Rheumatology Progress Note
Rotator Cuff Tear
Sexual Dysfunction - Chart Note
Shortness Of Breath - Progress Note
Sleep Apnea
Sleep Study Followup
SOAP - Cholecystitis
SOAP - Lung Mass
SOAP - Numbness & Tingling
SOAP - Shortness of Breath
SOAP - Substance Abuse
SOAP - Temporal Mass
Tethered Cord Evaluation
Three-Week Postpartum Checkup
Thrombocytopenia - SOAP Note
Thrombocytosis Followup
Total Abdominal Hysterectomy - Followup
URI - SOAP
Urinary Frequency & Urgency - Followup
Urinary Retention - Followup
Uterine Papillary Serous Carcinoma
Wasp Sting - SOAP
Weight Loss on Phentermine
Wound Check - Status Post APR
Medical Specialty:
SOAP / Chart / Progress Notes
Sample Name: Dietary Consult - 3
Description: The patient is brought in by an assistant with some of his food diary sheets.
(Medical Transcription Sample Report)
SUBJECTIVE: The patient is brought in by an assistant with some of his food diary sheets. They wonder if the patient needs to lose anymore weight.
OBJECTIVE: The patient's weight today is 186-1/2 pounds, which is down 1-1/2 pounds in the past month. He has lost a total of 34-1/2 pounds. I praised this. I went over his food diary and praised all of his positive food choices reported, especially his use of sugar-free Kool-Aid, sugar-free pudding, and diet pop. I encouraged him to continue all of that, as well as his regular physical activity.
ASSESSMENT: The patient is losing weight at an acceptable rate. He needs to continue keeping a food diary and his regular physical activity.
PLAN: The patient plans to see Dr. XYZ at the end of May 2005. I recommended that they ask Dr. XYZ what weight he would like for the patient to be at. Follow up will be with me June 13, 2005.
See More Samples on SOAP / Chart / Progress Notes
Acne - SOAP
Acquired Hypothyroidism Followup
Allergic Rhinitis
Anemia & Leukemia Followup
Aplastic Anemia Followup
Asperger Disorder
Atrial Fibrillation - SOAP
Atrial Flutter - Progress Note
Bell's Palsy
Breast Cancer Followup
Breast Cancer Followup - 1
Breast Radiation Therapy Followup
Bunions and Calluses
CAD - 6-Month Followup
Carbohydrate Counting
Cardiology Progress Note
Cardiology Progress Note - 1
Care Conference With Family
Cataract - Second Opinion
Cataract Extraction Followup
Cervical Spinal Stenosis
Cervicalgia
Chest Pain & Respiratory Insufficiency
Chiropractic Progress Note
Chronic Kidney Disease Followup
Chronic Kidney Disease Followup - 1
Chronic Medical Conditions - Followup
Circumcision Followup
Clostridium Difficile Colitis Followup
COPD & Pneumonia - SOAP
Craniopharyngioma - Postop
CyberKnife Treatment - Followup
D&C & Hysteroscopy Followup
Dermatitis - SOAP
Deviated Septum Repair - Followup
Diabetes Mellitus - SOAP Note - 1
Diabetes Mellitus - SOAP Note - 2
Diabetes Mellitus Followup
Diabetic Foot Care
Dietary Consult - 1
Dietary Consult - 2
Dietary Consult - 3
Dietary Consult - 4
Dietary Consult - Diabetes - 1
Dietary Consult - Diabetes - 2
Dietary Consult - Gestational Diabetes
Dietary Consult - Hyperlipidemia
Dietary Consult - Weight Reduction
Down's syndrome
E. Coli UTI - Followup
Elevated PSA - Chart Note
Endometrial Cancer Followup
Erectile Dysfunction - Followup
Evaluation of Allergies
Facial Rhytids
Fifth Disease - SOAP
Followup Screw Fixation
Foot Lesions
Foot Pain - SOAP
Foreskin - Followup
Fundoplication & Gastrostomy Followup
Gastric Bypass - Preop Eval
Gen Med Progress Note
Gen Med Progress Note - 1
Gen Med Progress Note - 10
Gen Med Progress Note - 11
Gen Med Progress Note - 12
Gen Med Progress Note - 13
Gen Med Progress Note - 2
Gen Med Progress Note - 3
Gen Med Progress Note - 4
Gen Med Progress Note - 5
Gen Med Progress Note - 6
Gen Med Progress Note - 7
Gen Med Progress Note - 8
Gen Med Progress Note - 9
Gen Med SOAP
Gen Med SOAP - 1
Gen Med SOAP - 10
Gen Med SOAP - 11
Gen Med SOAP - 2
Gen Med SOAP - 3
Gen Med SOAP - 4
Gen Med SOAP - 5
Gen Med SOAP - 6
Gen Med SOAP - 7
Gen Med SOAP - 8
Gen Med SOAP - 9
Hand Discomfort - Followup
HIV Followup
HIV Followup - 1
Hypertension - Progress Note
Infected Toenails
Ischemic Cardiac Disease - Progress Note
Laminectomy & Foraminotomy Followup
Lap Band Adjustment
Leg Pain - Progress Note
Leg Pain & Bone Pain
Lobectomy - Followup
Low Back Pain from Exercise
Lung Biopsy Discussion
Lung Cancer Followup
Mantle Cell Lymphoma
Melena - ICU Followup
Mesothelioma - Chart Note
MGUS Followup
Multiple Medical Problems
Multiple Progress Notes
Nephrolithiasis - Progress Note
Neurologic Examination
Non-Hodgkin lymphoma Followup
Obesity Hypoventilation Syndrome
Ophthalmology Progress Note - 1
Ophthalmology Progress Note - 2
ORIF - Followup
ORIF Facial Fractures - Followup
Osteoarthritis - Progress Note
Overactive Bladder
PAF - 6-Month Followup
Pain Management Progress Note
Physical Therapy - Outpatient Rehab
Plantar Fasciitis
Podiatry - Progress Note
Poison Ivy - SOAP
Polycythemia Rubra Vera
Polycythemia Vera Followup
Possible Spider Bite
Postop Parathyroid Exploration & Parathyroidectomy
Posttransplant Lymphoproliferative Disorder
Progress Note - Iron Deficiency Anemia
Progress Note - Liver Cirrhosis
Progress Note - Supraglottitis
Prostate Adenocarcinoma - 1
Prostate Adenocarcinoma - 2
Prostate Adenocarcinoma - 3
Prostate Adenocarcinoma - 4
Prostate Fossa Irradiation - Followup
Prostatitis - Recheck
Pulmonary - Followup Note
Pulmonary Medicine Clinic Followup
Q-Fever Endocarditis
Recheck of ADHD Meds
Refractory Hypertension - Followup
Rheumatology Progress Note
Rotator Cuff Tear
Sexual Dysfunction - Chart Note
Shortness Of Breath - Progress Note
Sleep Apnea
Sleep Study Followup
SOAP - Cholecystitis
SOAP - Lung Mass
SOAP - Numbness & Tingling
SOAP - Shortness of Breath
SOAP - Substance Abuse
SOAP - Temporal Mass
Tethered Cord Evaluation
Three-Week Postpartum Checkup
Thrombocytopenia - SOAP Note
Thrombocytosis Followup
Total Abdominal Hysterectomy - Followup
URI - SOAP
Urinary Frequency & Urgency - Followup
Urinary Retention - Followup
Uterine Papillary Serous Carcinoma
Wasp Sting - SOAP
Weight Loss on Phentermine
Wound Check - Status Post APR
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