Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Obstetrics / Gynecology
Sample Name: Total Abdominal Hysterectomy - Followup

Description: Postoperative day #1, total abdominal hysterectomy. Normal postoperative course.
(Medical Transcription Sample Report)

POSTOPERATIVE DAY #1, TOTAL ABDOMINAL HYSTERECTOMY

SUBJECTIVE: The patient is alert and oriented x3 and sitting up in bed. The patient has been ambulating without difficulty. The patient is still NPO. The patient denies any new symptomatology from 6/10/2009. The patient has complaints of incisional tenderness. The patient was given a full explanation about her clinical condition and all her questions were answered.

OBJECTIVE:
VITAL SIGNS: Afebrile now. Other vital signs are stable.
GU: Urinating through Foley catheter.
ABDOMEN: Soft, negative rebound.
EXTREMITIES: Without Homans, nontender.
BACK: Without CVA tenderness.
GENITALIA: Vagina, slight spotting. Wound dry and intact.

ASSESSMENT: Normal postoperative course.

PLAN:
1. Follow clinically.
2. Continue present therapy.
3. Ambulate with nursing assistance only.



Keywords: obstetrics / gynecology, postoperative course, total abdominal hysterectomy, postoperative,
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