Transcribed Medical Transcription Sample Reports and Examples
MT HelpLine Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: SOAP / Chart / Progress Notes

Subjective, Objective, Assessment, Plan. Progress notes, followup notes, etc.

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Plantar Fasciitis
A 44-year-old, 250-pound male presents with extreme pain in his left heel.

Podiatry - Progress Note
Plantar fascitis/heel spur syndrome. The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate.

Poison Ivy - SOAP
Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak.

Polycythemia Rubra Vera
Polycythemia rubra vera. The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months.

Polycythemia Vera Followup
Followup for polycythemia vera with secondary myelofibrosis. JAK-2 positive myeloproliferative disorder. He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy.

Possible Spider Bite
A 47-year-old white female presents with concern about possible spider bite to the left side of her neck.

Postop Parathyroid Exploration & Parathyroidectomy
This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia. She has had an uneventful postoperative night.

Posttransplant Lymphoproliferative Disorder
Posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma of the skin, anemia secondary to chronic renal insufficiency and chemotherapy, and hypertension. The patient is here for followup visit and chemotherapy.

Progress Note - Iron Deficiency Anemia
Patient developed iron deficiency anemia and had blood in his stool.

Progress Note - Liver Cirrhosis
Patient seen initially with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating.

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NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples