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Transcribed Medical Transcription Sample Reports and Examples
Great Collection of Medical Transcription Samples
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SOAP / Chart / Progress Notes

D&C & Hysteroscopy Followup

D&C and hysteroscopy. Abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, and thickened endometrium per ultrasound of a 2 cm lining.
6. Grade 1+ rectocele.

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Chronic Medical Conditions – Followup

Followup evaluation and management of chronic medical conditions. Congestive heart failure, stable on current regimen. Diabetes type II, A1c improved with increased doses of NPH insulin. Hyperlipidemia, chronic renal insufficiency, and arthritis.

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Atrial Fibrillation – SOAP

Atrial fibrillation with rapid ventricular response, Wolff-Parkinson White Syndrome, recent aortic valve replacement with bioprosthetic Medtronic valve, and hyperlipidemia.

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COPD & Pneumonia – SOAP

Acute on chronic COPD exacerbation and community acquired pneumonia both resolving. However, she may need home O2 for a short period of time.

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Cataract Extraction Followup

Patient follows up for cataract extraction with lens implant 2 weeks ago. Recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.

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Obesity Hypoventilation Syndrome

Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.

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