Medical Specialty:
SOAP / Chart / Progress Notes

Sample Name: Total Abdominal Hysterectomy - Followup

Description: Postoperative day #1, total abdominal hysterectomy. Normal postoperative course.
(Medical Transcription Sample Report)


SUBJECTIVE: The patient is alert and oriented x3 and sitting up in bed. The patient has been ambulating without difficulty. The patient is still NPO. The patient denies any new symptomatology from 6/10/2009. The patient has complaints of incisional tenderness. The patient was given a full explanation about her clinical condition and all her questions were answered.

VITAL SIGNS: Afebrile now. Other vital signs are stable.
GU: Urinating through Foley catheter.
ABDOMEN: Soft, negative rebound.
EXTREMITIES: Without Homans, nontender.
BACK: Without CVA tenderness.
GENITALIA: Vagina, slight spotting. Wound dry and intact.

ASSESSMENT: Normal postoperative course.

1. Follow clinically.
2. Continue present therapy.
3. Ambulate with nursing assistance only.

Keywords: soap / chart / progress notes, postoperative course, total abdominal hysterectomy, postoperative,