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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SOAP - Numbness & Tingling
Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist. Carpal tunnel syndrome suspected.

SOAP - Shortness of Breath
The patient is admitted for shortness of breath, continues to do fairly well. The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72. The patient did undergo echocardiogram, which shows aortic stenosis, severe. The patient does have an outside cardiologist.

SOAP - Substance Abuse
He got addicted to drugs. He decided it would be a good idea to get away from the "bad crowd" and come up and live with his mom.

SOAP - Temporal Mass
MRI demonstrated right contrast-enhancing temporal mass.

Tethered Cord Evaluation
Evaluation of possible tethered cord. She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.

Three-Week Postpartum Checkup
The patient comes for three-week postpartum checkup, complaining of allergies.

Thrombocytopenia - SOAP Note
Patient with immune thrombocytopenia

Thrombocytosis Followup
Essential thrombocytosis. He underwent a bone marrow biopsy, which showed essential thrombocytosis. His CBC has been very stable.

Total Abdominal Hysterectomy - Followup
Postoperative day #1, total abdominal hysterectomy. Normal postoperative course.

URI - SOAP
Sore throat - Upper respiratory infection.

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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