Transcribed Medical Transcription Sample Reports and Examples

Show All Hide All

Autopsy
1. Autopsy - 1
2. Autopsy - 2
3. Autopsy - 3
4. Autopsy - 4
5. Autopsy - 5
6. Autopsy - 6
7. Autopsy - 7
Cardiovascular / Pulmonary
1. 2-D Echocardiogram - 1
2. 2-D Echocardiogram - 2
3. 2-D Echocardiogram - 3
4. Acute Inferior Myocardial Infarction
5. Angina
6. Arterial Imaging
7. Bronchoscopy - 1
8. Bronchoscopy - 2
9. Bronchoscopy - 3
10. Bronchoscopy - 4
11. Bronchoscopy - 5
12. Bronchoscopy - 6
13. Bronchoscopy - Pediatric
14. Cardiac Allograft Transplant
15. Cardiac Catheterization - 1
16. Cardiac Catheterization - 2
17. Cardiac Catheterization - 3
18. Cardiac Catheterization - 4
19. Cardiac Catheterization - 5
20. Cardiac Catheterization - 6
21. Cardiac Catheterization - 7
22. Cardiac Consultation - 1
23. Cardiac Consultation - 2
24. Cardio/Pulmo Discharge Summary
25. Cardiology - Letter
26. Cardiology Office Visit - 1
27. Cardiology Office Visit - 2
28. Cardiology Progress Note
29. Cardiovascular - Letter
30. Carotid & Cerebral Arteriograms
31. Central Line Placement
32. Chest Tube Insertion in ER
33. Duplex Ultrasound - Legs
34. ER Report - Chest Pain.
35. ER Report - COPD
36. Flexible Bronchoscopy.
37. Followup on Asthma
38. H&P - Cardio (Angina)
39. Holter Monitoring
40. Hypertension - Progress Note
41. Ischemic Cardiac Disease - Progress Note
42. Laryngoscopy
43. Lobectomy - VATS
44. Lobectomy & Lymphadenectomy
45. Lung Biopsy Discussion
46. Mayoview
47. Metastasectomy & Bronchoscopy
48. Microlaryngoscopy
49. MRI of Lung - Adenocarcinoma
50. Myocardial Perfusion Imaging - 1
51. Myocardial Perfusion Imaging - 2
52. Myoview Perfusion Scan
53. Pacemaker (Dual Chamber)
54. Pacemaker Insertion
55. Pleurocentesis
56. Pneumothorax & Subcutaneous Emphysema
57. Pulmonary - Followup Note
58. Pulmonary Consultation
59. Pulmonary Function Test - 1
60. Pulmonary Function Test - 2
61. Pulmonary Medicine Clinic Followup
62. Stress Test Adenosine Myoview
63. Stress Test Bruce Protocol
64. Stress Test Dobutamine
65. Stress Test Dobutamine Myoview
66. Stress Test Dobutrex
67. Stress Test Graded Exercise Treadmill
68. Stress Test Thallium
69. Subxiphoid Pericardial Window
70. Thoracoscopy/Thoracotomy
71. Thoracotomy & Lobectomy
72. Tracheostomy
73. Ultrasound - Carotid - 1
74. Ultrasound - Carotid - 2
Chiropractic - Pain Mang
1. Acromioclavicular Joint Injection
2. Bilateral Carpal Tunnels Injection
3. Bilateral sacroiliac joint injections
4. Botox Injection - Trigger Point
5. Bursal Injection
6. Caudal Epidural Steroid Injection
7. Cervical Facet Joint Injection
8. Cervical Selective Nerve Root Block
9. Chiropractic IME - 1
10. Chiropractic IME - 2
11. Chiropractic Initial Evaluation - 1
12. Chiropractic Initial Evaluation - 2
13. Chiropractic Progress Note
14. Coccygeal injection
15. Costochondral Cartilage Injection
16. Epidural Steroid Injection
17. Foot pain Consultation
18. Knee & Back pain
19. Knee Injection
20. Lower Extremity Pain
21. Mortons Neuroma Injection
22. Neck & Back pain.
23. Pain Management Consult - 1
24. Pain Management Consult - 2
25. Pain Management Progress Note
26. Permanent & Stationary Report
27. Plantar Fascia Injection
28. Qualified Medical Evaluation Report
29. Shoulder Pain Consult
30. Superior Gluteal Nerve Block
31. Wrist pain
Consult - History and Phy.
1. 1-month-old Checkup
2. Acne Vulgaris - H&P
3. Acute Cystitis & Diabetes Type II
4. Acute Inferior Myocardial Infarction
5. Ankle Pain - Consult
6. Ankle Sprain - H&P
7. Bladder Instillation
8. Bunion & Pes Planovalgus Deformity
9. Burn - Consult
10. Carbohydrate Counting
11. Cardiac Consultation - 1
12. Cardiac Consultation - 2
13. Consult - Chest Pain
14. Consult - Hypertension
15. Consult - ICU Management
16. Consult - Prostate Cancer
17. Consult - Weankness & Polymyositis
18. Cough & Abdominal Pain
19. Dietary Consult - 1
20. Dietary Consult - 2
21. Dietary Consult - 3
22. Dietary Consult - 4
23. Dietary Consult - Diabetes
24. Dietary Consult - Gestational Diabetes
25. Dietary Consult - Hyperlipidemia
26. Dietary Consult - Weight Reduction
27. Dietary Consultation - 1
28. Dietary Consultation - 2
29. Ear Pain - Drainage
30. Ear pain - Pediatric Consult
31. Elevated PSA - H&P
32. Eye Examination - H&P
33. First Pap smear.
34. Foot pain Consultation
35. Gen Med Consult - 1
36. Gen Med Consult - 10
37. Gen Med Consult - 11
38. Gen Med Consult - 12
39. Gen Med Consult - 13
40. Gen Med Consult - 14
41. Gen Med Consult - 15
42. Gen Med Consult - 16
43. Gen Med Consult - 17
44. Gen Med Consult - 18
45. Gen Med Consult - 19
46. Gen Med Consult - 2
47. Gen Med Consult - 20
48. Gen Med Consult - 21
49. Gen Med Consult - 22
50. Gen Med Consult - 23
51. Gen Med Consult - 3
52. Gen Med Consult - 4
53. Gen Med Consult - 5
54. Gen Med Consult - 6
55. Gen Med Consult - 7
56. Gen Med Consult - 8
57. Gen Med Consult - 9
58. Gen Med H&P - 1
59. Gen Med H&P - 2
60. GI Consultation - 1
61. GI Consultation - 2
62. GI Consultation - 3
63. GI Consultation - 4
64. H&P - Cardio (Angina)
65. H&P - Gen Med - 1
66. H&P - Gen Med - 2
67. H&P - Infant with fever
68. H&P - Weakness
69. Hyperesthesia
70. Hyperthyroidism Following Pregnancy
71. Low Back Pain - Consult
72. Lumbar Radiculopathy - Consult
73. Lumbar Spine HNP - Consult
74. Lymphoma - Consult
75. Major Depressive Disorder - IME Consult
76. Neck & Back pain.
77. Nephrology Consultation - 1
78. Nephrology Consultation - 2
79. OB/GYN - H&P
80. OB/GYN Consultation - 1
81. OB/GYN Consultation - 2
82. OB/GYN Consultation - 3
83. OB/GYN Consultation - 4
84. Onychomycosis - H&P
85. Orthopedic Consult - 1
86. Orthopedic Consult - 2
87. Orthopedic Consult - 3
88. Otitis Media - H&P
89. Pain Management Consult - 1
90. Pain Management Consult - 2
91. Physical Exam and Pap
92. Pneumothorax & Subcutaneous Emphysema
93. Prostate Adenocarcinoma - H&P
94. Psych Consult - Alcohol Withdrawal
95. Psych Consult - Altered Mental Status
96. Psych Consult - Anxiety
97. Psych Consult - Dementia
98. Psych Consult - Depression - 1
99. Psych Consult - Depression - 2
100. Psych Consult - Lethargy
101. Psych Consult - Pain Meds
102. Psych Consult - Substance abuse
103. Psych H&P - 1
104. Psych H&P - 2
105. Pulmonary Consultation
106. Request For Consultation
107. Rheumatoid Arthritis - H&P
108. Rotator cuff syndrome - H&P
109. School Physical - 1
110. School Physical - 2
111. Shoulder Pain Consult
112. Small Bowel Obstruction
113. Sports Physical - 1
114. Sports Physical - 2
115. Sports Physical - 3
116. Thrombocytopenia
117. TIA - Cosult
118. Tinea Pedis - H&P
119. Trouble Breathing - H&P
120. Urology Consut - 1
121. Well-Child Check
122. Well-woman checkup
123. Worker�s Compensation Injury
124. Wrist pain
Dermatology
1. Acne Vulgaris
2. Acne Vulgaris - H&P
3. Atopic Eczema
4. Burn - Consult
5. Hyperesthesia
6. Poison Ivy - SOAP
7. Wasp Sting - SOAP
Diets and Nutritions
1. Carbohydrate Counting
2. Dietary Consult - 1
3. Dietary Consult - 2
4. Dietary Consult - 3
5. Dietary Consult - 4
6. Dietary Consult - Diabetes
7. Dietary Consult - Gestational Diabetes
8. Dietary Consult - Hyperlipidemia
9. Dietary Consult - Weight Reduction
Discharge Summary
1. Cardio/Pulmo Discharge Summary
2. Discharge Summary - Urology.
3. Psychiatric Discharge Summary - 1
4. Psychiatric Discharge Summary - 2
5. Urology Discharge Summary
Emergency Room Reports
1. Acute Inferior Myocardial Infarction
2. Blood per Rectum
3. Chest Tube Insertion in ER
4. Closed Head Injury
5. Colostomy Failure
6. Consult - ICU Management
7. ER Report - Chest Pain.
8. ER Report - COPD
9. ER Report - URI
10. Fall & Laceration
11. Headache - Urgent Care Visit
12. Intracranial aneurysm - ER Visit
13. Proctitis & Proctocolitis
ENT - Otolaryngology
1. Adenoidectomy
2. Bilateral Myringotomies
3. BMT - Bilateral Myringotomy Tubes
4. Ear Cartilage Graft
5. Ear Pain - Drainage
6. Ear pain - Pediatric Consult
7. Laryngoscopy
8. Microlaryngoscopy
9. Middle Ear Exploration
10. Myringotomy/Tube Insertion - 1
11. Myringotomy/Tube Insertion - 2
12. Myringotomy/Tube Insertion - 3
13. Otitis Media
14. Otitis Media - H&P
15. Parotidectomy
16. Rhinectomy & Nasal Endoscopy
17. Rhinoplasty
18. Sample Normal Exam - ENT
19. Septoplasty
20. Septoplasty & Turbinectomy
21. Septorhinoplasty
22. Sinus Fractures Repairs
23. SOM - Serous Otitis Media
24. Thoracoscopy/Thoracotomy
25. Tonsillectomy & Adenoidectomy
26. Tonsillectomy and Septoplasty
27. Tympanomastoidectomy
Gastroenterology
1. Blood per Rectum
2. Cholecystectomy - Laparoscopic
3. Cholecystectomy - Open
4. Colonoscopy - 1
5. Colonoscopy - 2
6. Colonoscopy - 3
7. Colonoscopy - 4
8. Colostomy Failure
9. EGD with Dilation
10. Endoscopy
11. Endoscopy Template
12. ERCP
13. Esophagogastroduodenoscopy
14. Flex Sig - 1
15. Gastroenterology - Letter
16. GI Consultation - 1
17. GI Consultation - 2
18. GI Consultation - 3
19. GI Consultation - 4
20. Proctitis & Proctocolitis
21. Small Bowel Obstruction
22. Stamm Gastrostomy Tube Placement
23. Upper Endoscopy - Foreign Body Removal
General Medicine
1. Acute Cystitis & Diabetes Type II
2. Burn - Consult
3. Consult - Chest Pain
4. Consult - Hypertension
5. Cough & Abdominal Pain
6. Diabetes Mellitus - SOAP Note
7. Down�s syndrome
8. ER Report - URI
9. Fall & Laceration
10. Female Exam & ROS
11. Female Physical Exam - 1
12. Female Physical Exam - 2
13. Female ROS
14. Fifth Disease - SOAP
15. Followup on Asthma
16. Gen Med Consult - 1
17. Gen Med Consult - 10
18. Gen Med Consult - 11
19. Gen Med Consult - 12
20. Gen Med Consult - 13
21. Gen Med Consult - 14
22. Gen Med Consult - 15
23. Gen Med Consult - 16
24. Gen Med Consult - 17
25. Gen Med Consult - 18
26. Gen Med Consult - 19
27. Gen Med Consult - 2
28. Gen Med Consult - 20
29. Gen Med Consult - 21
30. Gen Med Consult - 22
31. Gen Med Consult - 23
32. Gen Med Consult - 3
33. Gen Med Consult - 4
34. Gen Med Consult - 5
35. Gen Med Consult - 6
36. Gen Med Consult - 7
37. Gen Med Consult - 8
38. Gen Med Consult - 9
39. Gen Med H&P - 1
40. Gen Med H&P - 2
41. Gen Med Progress Note - 1
42. Gen Med Progress Note - 10
43. Gen Med Progress Note - 2
44. Gen Med Progress Note - 3
45. Gen Med Progress Note - 4
46. Gen Med Progress Note - 5
47. Gen Med Progress Note - 5
48. Gen Med Progress Note - 6
49. Gen Med Progress Note - 7
50. Gen Med Progress Note - 8
51. Gen Med Progress Note - 9
52. Gen Med SOAP - 1
53. Gen Med SOAP - 2
54. Gen Med SOAP - 3
55. Gen Med SOAP - 4
56. Gen Med SOAP - 5
57. Gen Med SOAP - 6
58. Gen Med SOAP - 7
59. H&P - Gen Med - 1
60. H&P - Gen Med - 2
61. H&P - Weakness
62. Headache - Urgent Care Visit
63. Hyperthyroidism Following Pregnancy
64. Male Exam & ROS
65. Normal Male Exam Template - 1
66. Normal Male Exam Template - 2
67. Normal Male ROS Template - 1
68. Physical Exam and Pap
69. Possible Spider Bite
70. Pressure decubitus
71. Request For Consultation
72. Snoring
73. Trouble Breathing - H&P
74. URI - SOAP
Hematology - Oncology
1. BCCa Excision - Canthus
2. BCCa Excision - Cheek
3. BCCa Excision - Lower Lid
4. BCCa Excision - Nasal Tip
5. Biopsy - Cervical Lymph Node
6. Consult - Breats Cancer
7. Lymphoma - Consult
8. Thrombocytopenia
Hospice - Palliative Care
1. Hospice Visit - AIDS
2. Hospice Visit - CA of Cervix
3. Hospice Visit - CHF
4. Hospice Visit - Colon Cancer
IME, QME, Work. Comp. etc.
1. Burn - Consult
2. Chiropractic IME - 1
3. Chiropractic IME - 2
4. Major Depressive Disorder - IME Consult
5. Permanent & Stationary Report
6. Qualified Medical Evaluation Report
Letters
1. Abnormal Cholesterol Result - Letter
2. Cardiology - Letter
3. Cardiovascular - Letter
4. Gastroenterology - Letter
5. Optometry - Letter
6. Pediatric - Letter
7. Urology Letter
Nephrology
1. AV Fistula - 1
2. AV Fistula - 2
3. AV Fistula - 3
4. AV Fistula - 4
5. AV Fistula - 5
6. Nephrectomy - Partial
7. Nephrectomy - Partial (Laparoscopic )
8. Nephrectomy - Radical
9. Nephrectomy - Radical (Laparoscopic)
10. Nephrectomy - Transplant
11. Nephrolithiasis - Progress Note
12. Nephrology Consultation - 1
13. Nephrology Consultation - 2
14. Nephrology Office Visit - 1
15. Nephrology Office Visit - 2
16. Psychosocial Eval - Donor
17. Psychosocial Eval for Kidney Transplant
18. Renal Transplant - Cadaveric
19. Ultrasound - Kidney
Neurology
1. Acute Intracerebral Hemorrhage
2. Alzheimer's Disease
3. Arachnoid Cyst
4. Arnold Chiari II with Syrinx
5. Astrocytoma
6. AVM with Hemorrhage
7. Bell�s Palsy
8. Brain MRI - Pituitary Adenoma
9. Brain Stimulator Electrode
10. Cerebral Angiogram
11. Cerebral Angiogram - Lateral Medullary Syndrome
12. Cerebral Angiogram - Left ICA/PCA Aneurysm
13. Cerebral Angiogram & MRA
14. Chest CT - Myasthenia Gravis
15. Craniotomy - Biparietal
16. Craniotomy - Burr Hole
17. Craniotomy - Frontotemporal
18. Craniotomy - Occipital
19. Craniotomy - Retrosigmoid
20. Craniotomy - Temporal
21. Creutzfeldt-Jakob Disease
22. CT Brain
23. CT Brain - Aneurysm
24. CT Brain - Calcification of Basal Ganglia
25. CT Brain - Hemangioma
26. CT Brain - SAH
27. CT Brain - Stroke
28. CT Brain: Subdural hematoma
29. CT Brain: Subdural Hemorrhage.
30. CT Scan of Brain with Contrast
31. Dandy-Walker Malformation
32. Electroencephalography
33. HCT - Calcification of Basal Ganglia
34. HCT - Pituitary Mass
35. Hematoma Evacuation
36. Intracranial aneurysm - ER Visit
37. Moya Moya Disease
38. MRI Brain - Meningioma (Olfactory)
39. MRI Brain - Bilateral Thalamic Strokes
40. MRI Brain - Leukoencephalopathy
41. MRI Brain - Pilocytic Astrocytoma
42. MRI Brain - Pontine Stroke
43. MRI Brain - Progressive Aphasia
44. MRI Brain - SLE & Stroke
45. MRI Brain - Thrombus
46. MRI Brain - Toxoplasmosis
47. MRI Brain - Wernicke aphasia
48. MRI Brain & Cerebral Angiogram
49. MRI Brain and Brainstem
50. MRI Brain and C-T Spine
51. MRI Brain: Thalamic Infarct
52. MRI C-spine
53. MRI C-Spine - C5-6 Disk Herniation
54. MRI L-S Spine - Cauda Equina Syndrome
55. MRI L-Spine - Subarachnoid Seeding
56. MRI of Brain w/o Contrast.
57. MRI T-L Spine - Schistosomiasis
58. MRI T-spine
59. MRI T-Spine - Spinal Mets
60. Neuropsychological Evaluation
61. Normal L-Spine MRI
62. Pituitary Adenomectomy
63. SAH, Contusion, Skull Fracture
64. Sleep Study Interpretation
65. TIA - Cosult
Neurosurgery
1. Brain Stimulator Electrode
2. Craniotomy - Biparietal
3. Craniotomy - Burr Hole
4. Craniotomy - Frontotemporal
5. Craniotomy - Occipital
6. Craniotomy - Retrosigmoid
7. Craniotomy - Temporal
8. Hematoma Evacuation
9. Pituitary Adenomectomy
10. Scott Cannula
Obstetrics / Gynecology
1. Complete Physical - Female
2. Cone Biopsy
3. Delivery Note - 1
4. Delivery Note - 2
5. Dilatation & Curettage - D&C
6. First Pap smear.
7. Hemivulvectomy
8. Hysterectomy & Salpingoophorectomy
9. Hysterectomy (TAH - BSO)
10. Hysteroscopy & Endometrial Ablation
11. Laparoscopic Hysterectomy
12. Laser of Vulva
13. OB/GYN - H&P
14. OB/GYN Consultation - 1
15. OB/GYN Consultation - 2
16. OB/GYN Consultation - 3
17. OB/GYN Consultation - 4
18. Physical Exam and Pap
19. Pre-Eclampsia & Eclampsia
20. Radical Hysterectomy
21. Radical Vulvectomy
22. Three-Week Postpartum Checkup
23. Tubal Fulguration - Laparoscopic
24. Ultrasound - OB
25. Ultrasound - Pelvis
26. Ultrasound - Transvaginal
27. Well-woman checkup
Office Notes
1. Cardiology Office Visit - 1
2. Cardiology Office Visit - 2
3. Nephrology Office Visit - 1
4. Nephrology Office Visit - 2
5. Normal Male Exam Template - 1
6. Normal Male Exam Template - 2
7. Normal Male ROS Template - 1
8. Post Dilation Instructions
Ophthalmology
1. BCCa Excision - Lower Lid
2. Blepharon & Entropion Repair
3. Blepharoplasty
4. Blepharoplasty - Direct Brow Repair
5. Blepharoplasty - Lower Lid
6. Blepharoplasty - Quad
7. Browlift, Blepharoplasty, & Rhytidectomy
8. Cataract
9. Conjunctivitis
10. Eye Examination - H&P
11. Lid Laceration Repair
12. Midface Lift & Blepharoplasty
13. Ophthalmology Progress Note - 1
14. Ophthalmology Progress Note - 2
15. Optometry - Letter
16. Phacoemulsification
17. Phacoemulsification of Cataract
18. Post Dilation Instructions
19. Rhytidectomy & Blepharoplasty
20. Ruptured Globe Repair - Cornea
21. Ruptured Globe Repair - Posterior Sclera
22. Ruptured Globe Repair - Sclera and Limbus
23. Trabeculectomy
24. Tube Shunt - Ahmed Valve Implant
Orthopedic
1. Achilles Ruptured Tendon
2. Ankle Pain - Consult
3. Ankle Sprain - H&P
4. Arthroscopy Shoulder/Knee
5. Bunion & Pes Planovalgus Deformity
6. Carpal Ligament Release - 1
7. Carpal Ligament Release - 2
8. Carpal Tunnel Release - 1
9. Carpal Tunnel Release - 2
10. Carpal Tunnel Release - 3
11. Carpal Tunnel Release - 4
12. Cervicalgia
13. CT of Lumbar Spine w/o Contrast
14. Diskectomy
15. FCR tendinitis
16. Finger triggering and locking
17. Foot pain Consultation
18. Knee & Back pain