Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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View this sample in Blog format on MedicalTranscriptionSamples.com

Sample Type / Medical Specialty: Ophthalmology
Sample Name: Ophthalmology Progress Note - 1

Description: Ophthalmology followup visit note.
(Medical Transcription Sample Report)

Visual acuities at this date were measured at 20/25 in the right eye and 20/20 in the left eye with correction. Pupils were equal, round, and reactive to light with no afferent pupillary defects. Extraocular muscle movements were smooth and full. Intraocular pressures were measured at 18 mmHg in the right eye and 20 mmHg in the left eye, by applanation. A dilated fundus examination was performed using a 20-diopter lens with the binocular indirect ophthalmoscope. The examination revealed retinal pigmentary epithelial changes in both eyes with no holes, tears, or detachments apparent around 360 degrees of either retina.

She is stable at this time and does not require any intervention at today's visit. I have asked her to return in six months' for a followup dilated examination, but would be happy to see her sooner should you or she notice any changes in her vision.

Keywords: ophthalmology, visual acuities, extraocular muscle, intraocular pressure, pupils, afferent, applanation, binocular, dilated fundus, left eye, lens, movements, ophthalmoscope, pigmentary, retina, retinal, right eye, acuities,
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