SOAP / Chart / Progress Notes
Sample Name: Lap Band Adjustment
Description: Patient status post lap band placement.
(Medical Transcription Sample Report)
REASON FOR VISIT: Lap band adjustment.
HISTORY OF PRESENT ILLNESS: Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment. Apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress. She was in a car accident a couple of weeks ago and she has problems, she does not feel full. She states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night, having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better.
PHYSICAL EXAMINATION: On exam, her temperature is 98, pulse 76, weight 197.7 pounds, blood pressure 102/72, BMI is 38.5, she has lost 3.8 pounds since her last visit. She was alert and oriented in no apparent distress.
PROCEDURE: I was able to access her port. She does have an AP standard low profile. I aspirated 6 mL, I did add 1 mL, so she has got approximately 7 mL in her band, she did tolerate water postprocedure.
ASSESSMENT: The patient is status post lap band adjustments, doing well, has a total of 7 mL within her band, tolerated water postprocedure. She will come back in two weeks for another adjustment as needed.
Keywords: soap / chart / progress notes, lap band adjustment, lap band placement, lap band,