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: Multiple Progress Notes

Description: Multiple Progress Notes for different dates in a patient with respiratory failure, on ventilator.
(Medical Transcription Sample Report)

PROGRESS NOTES

4/16/01:
Patient in respiratory failure, on ventilator
Request airline placement
Airline tracing good

4/17/01:
S: Sedated, intubated in NAD
O: Lungs: Increased bibasilar crackles
A/P: Respiratory arrest, pneumonia, COPD exacerbation
Replete K+, continue IVABX, start TPN, decrease TV, review ABGs

4/18/01:
S: Sedated and intubated, one episode NSVT
O: ABGs: 7.38/67/86/97

4/19/01:
S: Sedated and intubated, scant blood material from NGT
A/P: 1) Respiratory arrest
2) Exacerbation COPD - gastro cath NG aspiration

4/20/01:
S: Intubated/sedated, w/ NAD
O: Pulmonary - Increase L. basilar inspiration
A/P: Pneumonia
Respiratory arrest
COPD exacerbation
New onset low grade fever
D/C NGT - suspect sensitivity

4/20/01:
O: Preliminary blood culture gram + cocci
Dr. A called w/ result, no orders left
Pt. afebrile, WBC increase to 20.2
ABGs improved from 4/20/01, pt. noted to have less secretions
Last night had 8 beat run V-Tach

4/21/01:
O: Chest x-rays reviewed - improvement in lower lobe infiltrate
Gram + cocci in blood
Sputum H. influen. gram neg.

4/22/01:
atient up in chair
Decrease ventilator support
Preliminary blood cultures - Staph coag neg 1 of 2

04/23/01:
S: Awake, alert in NAD
O: Temp 99.8
Blood cultures: Staph coag. Neg. 1 of 2
A/P: Pneumonia, respiratory arrest, COPD
Continue wearing tirals

4/24/01:
S: Awake and alert, +N, refused trach
If fails extubation, will allow for reintubation
O: Temp. 99.4
ABGs: 7.9/52/70/94%
A/P: Pneumonia, respiratory arrest, COPD
Continue wearing tirals

4/24/01:
O: Patient off ventilator since this am

4/25/01:
S: Feeling well, no complaints
O: Temp. 99.4
A/P: Doing well s/p extubation
Change meds to po, advance diet

4/26:
S: Doing better, ambulating as same as yesterday
O: Temp. 97.9
A/P: Doing well, discontinue Foley
Plan to discharge home soon

4/2701:
O: Temp 97.8
A: Pneumonia, COPD

04/28/01:
Recurrent acute exacerbation of COPD

04/29/01:
O: Chest clear
Doing well

04/30/01:
S: Feeling better
O: Temp. 97.2
A/P: 4 + WBCs, sputum mod. gram neg. cocci, neg. blood infiltrates
Endstage COPD
D/C home

Keywords: soap / chart / progress notes, multiple progress notes, respiratory failure, ventilator, intubated, bibasilar crackles, pneumonia, copd, exacerbation, sedated and intubated, gram + cocci, gram +, gram neg, blood cultures, staph coag, progress notes, respiratory arrest, abgs, respiratory,
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