Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Diabetic Foot Care

Description: An 83-year-old diabetic female presents today stating that she would like diabetic foot care.
(Medical Transcription Sample Report)

S - An 83-year-old diabetic female presents today stating that she would like diabetic foot care.

O - On examination, the lateral aspect of her left great toenail is deeply ingrown. Her toenails are thick and opaque. Vibratory sensation appears to be intact. Dorsal pedal pulses are 1/4. There is no hair growth seen on her toes, feet or lower legs. Her feet are warm to the touch. All of her toenails are hypertrophic, opaque, elongated and discolored.

A - 1. Onychocryptosis.
2. Onychomycosis.
3. Difficulty in walking. The patients' toenails have made wearing shoe gear painful.

P - Aseptic technique was used and the lateral aspect of the left great toenail was excised. Blood loss was minimal. Hemostasis was achieved. Her left great toe was dressed with Neosporin ointment and absorbent dressing. Her remaining toenails required manual as well as electric debridement. Followup is every three months or whenever she needs to come in.

Keywords: soap / chart / progress notes, onychocryptosis, onychomycosis, great toenail, diabetic foot care, diabetic foot, foot, toenail, ingrown, toenails, diabetic,
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