Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Physical Medicine - Rehab

Physician evaluation and treatment of, and coordination of care for, persons with musculoskeletal injuries, pain syndromes, and/or other physical or cognitive impairments or disabilities.



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Encephalopathy - Rehab Consult
Encephalopathy related to normal-pressure hydrocephalus.

Hip Fracture - Rehab Consult
Status post left hip fracture and hemiarthroplasty. Rehab transfer as soon as medically cleared.

Occupational Therapy Discharge Summary
Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.

Physical Therapy - Ankle Sprain
Ankle sprain, left ankle. The patient tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.

Physical Therapy - Back Pain
Patient was referred to Physical Therapy, secondary to low back pain and degenerative disk disease. The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms. The patient would benefit from skilled physical therapy intervention.

Physical Therapy - Brain Tumor Removal
Status post brain tumor removal. The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.

Physical Therapy - Low Back Pain
The patient is a 26-year-old female, referred to Physical Therapy for low back pain. The patient has a history of traumatic injury to low back.

Physical Therapy - Osteoarthritis
The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis. The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area. The patient was transferred from the hospital to a nursing home and lived there for 1 year. The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.

Physical Therapy - Outpatient Rehab
Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.

Physical Therapy - Synovitis
Synovitis - anterior cruciate ligament tear of the left knee. The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient fell in a grocery store. He reports slipping on a grape that was on the floor.

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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