Transcribed Medical Transcription Sample Reports and Examples
MT HelpLine Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Discharge Summary

A clinical report prepared by a physician or other health professional at the conclusion of a hospital stay or series of treatments. It outlines the patient's chief complaint, the diagnostic findings, the therapy administered and the patient's response to it, and recommendations on discharge.



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Ectopic Pregnancy - Discharge Summary
A 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding. Right ruptured ectopic pregnancy with hemoperitoneum. Anemia secondary to blood loss.

ER Report - Chest Pain & Fever
A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin.

ESRD - Discharge Summary
This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis and is also status post cadaveric kidney transplant with chronic rejection.

Falls - Discharge Summary
Falls at home. Anxiety and depression. The patient had been increasingly anxious and freely admitted that she was depressed at home.

Gastric Bypass Summary
Patient discharged after laparoscopic Roux-en-Y gastric bypass.

Gastroenteritis - Discharge Summary
Acute gastroenteritis, resolved. Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.

Gastrointestinal Bleed - Discharge Summary
Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids. Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.

GI Bleed - Discharge Summary
GI bleed. Upper gastrointestinal bleed. CBC revealed microcytic anemia.

Goldenhar Syndrome - Discharge Summary
Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency.

Hemiarthroplasty - Discharge Summary
Hemiarthroplasty, right hip. Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.

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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