Transcribed Medical Transcription Sample Reports and Examples
MT HelpLine Transcribed Medical Transcription Sample Reports and Examples
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as on 10/15/2020

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Sample Type / Medical Specialty: Discharge Summary

A clinical report prepared by a physician or other health professional at the conclusion of a hospital stay or series of treatments. It outlines the patient's chief complaint, the diagnostic findings, the therapy administered and the patient's response to it, and recommendations on discharge.

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Abscess with Cellulitis - Discharge Summary
Incision and drainage, first metatarsal head, left foot with culture and sensitivity.

Anterior Cervical Discectomy & Fusion - Discharge Summary
Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.

Back & Leg Pain - Discharge Summary
Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy. Chronic pain syndrome.

Back Pain - Discharge Summary
Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.

BRCA-2 mutation
Discharge summary of a patient with a BRCA-2 mutation.

Bronchiolitis - Discharge Summary
Bronchiolitis, respiratory syncytial virus positive; improved and stable. Innocent heart murmur, stable.

Cardiac Transfer Summary
Need for cardiac catheterization. Coronary artery disease, chest pain, history of diabetes, history of hypertension, history of obesity, a 1.1 cm lesion in the medial aspect of the right parietal lobe, and deconditioning.

Cardio/Pulmo Discharge Summary
A 49-year-old man with respiratory distress, history of coronary artery disease with prior myocardial infarctions, and recently admitted with pneumonia and respiratory failure.

Cellulitis - Discharge Summary
Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis. The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound.

Chest Pain & Respiratory Insufficiency
A lady was admitted to the hospital with chest pain and respiratory insufficiency. She has chronic lung disease with bronchospastic angina.

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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