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: Gen Med SOAP - 2

Description: Patient with NIDDM, hypertension, CAD status post CABG, hyperlipidemia, etc.
(Medical Transcription Sample Report)

SUBJECTIVE: Overall, she has been doing well. Her blood sugars have usually been less than or equal to 135 by home glucose monitoring. Her fasting blood sugar today is 120 by our Accu-Chek. She is exercising three times per week. Review of systems is otherwise unremarkable.

OBJECTIVE: Her blood pressure is 110/60. Other vitals are stable. HEENT: Unremarkable. Neck: Unremarkable. Lungs: Clear. Heart: Regular. Abdomen: Unchanged. Extremities: Unchanged. Neurologic: Unchanged.

ASSESSMENT:
1. NIDDM with improved control.
2. Hypertension.
3. Coronary artery disease status post coronary artery bypass graft.
4. Degenerative arthritis.
5. Hyperlipidemia.
6. Hyperuricemia.
7. Renal azotemia.
8. Anemia.
9. Fibroglandular breasts.

PLAN: We will get follow-up labs today. We will continue with current medications and treatment. We will arrange for a follow-up mammogram as recommended by the radiologist in six months, which will be approximately Month DD, YYYY. The patient is advised to proceed with previous recommendations. She is to follow-up with Ophthalmology and Podiatry for diabetic evaluation and to return for follow-up as directed.

Keywords: soap / chart / progress notes, general medicine, accu-chek, heent: unremarkable, hyperlipidemia, hypertension, lungs: clear, niddm, neck: unremarkable, progress note, soap, coronary artery bypass graft, follow-up labs, glucose monitoring, coronary artery,
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