medical transcription soap note examples

Abdomen: Soft, flat, nontender. He states he forgot to take his digoxin the last few days. The SOAP note is considered as the most effective and standard documentation used in the medical industry along with the progress note. However, the most common method of dictating the chart note is the SOAP … Continue present management. This looks to me like a psoriatic plaque. This would be unusual in both eyes anyway. OBJECTIVE: Temperature 99.6, blood pressure 132/82, pulse 80, respiratory rate 18, oxygen saturation 97% on room air. No rales, rhonchi or wheezes. We do not have any other good idea. Conjunctivae are clear; although, she does have some clear chemosis present bilaterally. PLAN: 2. Adnexa negative without adenopathy or nodularity or fixation. LAB RESULTS: Chest x-ray shows no acute findings by my reading. They were somewhat milder, and she did not seek medical attention. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. WBC 14.8, otherwise normal CBC. Examination of the legs reveals venous varicosities in the greater saphenous distribution of the right leg with significant trophic changes of chronic venous hypertension in the lower leg. 1. General: The patient is nontoxic appearing; although, her voice is raspy. Samples of Soap Notes Transcription Examples #5. SUBJECTIVE: The patient is here today with a tick bite on his upper right anterior thigh. MTHelpLine does not certify accuracy and quality of sample reports. HEENT: Atraumatic and normocephalic. We would like her to return for fasting chem-7, liver and lipid profiles, CBC, urinalysis and EKG. Chest:  Clear to P and A. All other systems are negative, except as noted in the HPI. Hypertension. frontier.edu. It is mandatory to procure user consent prior to running these cookies on your website. He does not have any pitting in his fingernails. She will have a screening colonoscopy performed. 1. This note is widely used in medical industry. Return in 6 months. She has had some clear tearing but no purulent discharge. The abdomen is soft and nontender with active bowel sounds. Neurology Sample Report #1. It is mandatory to procure user consent prior to running these cookies on your website. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. You will notice that most of the information in this medical transcription sample is brief, succinct, and has very … ER SOAP Note Medical Transcription Sample Reports, This site uses cookies like most sites on the Internet. SUBJECTIVE: The patient is a (XX)-year-old female who comes in today with a chief complaint of cough. MT Samples and Examples. SUBJECTIVE: The patient is a (XX)-year-old female, gravida 2, para 1, status post stage IIIA adenocarcinoma of the uterus with metastatic disease to the anterior peritoneum and left ovary. She does walk about a mile and a half a day. He has signed a consent form today. The patient is to take Benadryl and Claritin as needed. Knee-high Ace wraps/compression stockings were in place. These cookies will be stored in your browser only with your consent. 1. MT Word Help. No organomegaly. 3. Pupils are equal, round, and reactive to light. Samples of Soap Notes Transcription Examples #7. These transcribed medical transcription sample … Heart sounds are regular. She has no eye pain. Pupils are equal, round and reactive to light. She is to return for significant worsening of her symptoms, development of eye pain, worsening of her redness or swelling despite therapy or other concerns. He is to take his medications as directed. We told him he should follow up with a dermatologist in 2 to 4 weeks if it is not resolved. Dermatology SOAP Note Medical Transcription Sample Reports Dermatology SOAP Note Sample Report #1 SUBJECTIVE: The patient is a (XX)-year-old gentleman who comes in today for a … She will return in six months. The patient comes in without any dressing … NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. CHIEF COMPLAINT: Sore throat. Pupils are equal, round, react to light. He was given 6 mg of adenosine without conversion. Extraocular movements are intact. Every case at the hospital … EXTREMITIES: No clubbing, cyanosis or edema. She was given azithromycin in January with minimal relief. Bladder management: As previously mentioned, the patient is independent with intermittent catheterization. Pre-albuterol peak flow was documented at 125-150. No rectal masses are noted. She is hemodynamically stable for discharge. Dementia: Workup in progress. The lymphedema management team is assisting with his care. She will be seen by Pulmonary and then follow up with her primary care physician. As chart notes are short, medical transcription is performed for multiple notes as a single document and will be segregated after physician review. A baclofen pump was noted in the left lower quadrant of the abdomen. Cough and Congestion SOAP Note Transcription Sample Report SUBJECTIVE: The patient is a (XX)-month-old female who presents for a chief complaint of cough and congestion. The patient is 5 feet 8 inches tall and weighs 156 pounds. CVA: Without tenderness. No new creams, lotions or chemical detergents. Soap notes are often used to summarize a patient's pertinent information since a previous visit. These transcribed medical transcription sample … Follow up in three months with Dr. John Doe. Lungs: Clear. REVIEW OF SYSTEMS: Negative for fevers, chills, nausea, vomiting, diarrhea, constipation, headache, visual disturbances, neck pain, chest pain, shortness of breath or abdominal pain. This persisted and evolved into low-grade fever at 99 degrees, cough with occasional green sputum. He said he has had rosacea in the past and treated with some MetroGel. Urinary Retention SOAP Note Medical Transcription Sample Report. Samples of SOAP Notes Medical Transcription Examples SUBJECTIVE: The patient is a (XX)-year-old man with a history of chronic venous insufficiency and a prior venous ulcer. Gynecologic: Normal external genitalia. Extraocular movements are intact. Cookies can be disabled in your browser's settings. Breast Nodule SOAP Note Medical Transcription Sample Report. DIAGNOSIS: Acute supraventricular tachycardia, resolved. Surgically absent cervix. ASSESSMENT AND PLAN: A (XX)-year-old female presenting with allergic rhinitis and asthma. ER SOAP Note Sample #1. SUBJECTIVE:  The patient is a (XX)-year-old woman who comes in today for wart treatment on the feet. OBJECTIVE: On examination, he has an erythematous plaque on the scrotum, which is about 3 x 4 cm, slightly raised, confluent with irregular borders, not tender to touch. Troponin normal. SOAP Note Sample #4. He returns today for a preoperative evaluation prior to undergoing right greater saphenous vein stripping. PLAN: SOAP Note Medical Transcription Sample Reports SUBJECTIVE: This (XX)-year-old woman returns to the wound care center for followup of left plantar foot wound. SUBJECTIVE: The patient is complaining of sore throat for a few days. Useful Resources (Websites With Medical Transcription Examples and Sample Reports) For Medical Transcriptionists: Lots of useful word lists/operative sample reports on this site! OBJECTIVE: Her vital signs include a blood pressure of 112/82, pulse 62. DATE OF SERVICE: MM/DD/YYYY SUBJECTIVE: The patient is a (XX)-year-old man well known to us from prior evaluations for dementia. Labor & Delivery Medical SOAP Note. We have recommended a right greater saphenous vein stripping and ligation to lower his risk of recurrent venous ulceration. He removed it last night and notes that the tick was quite tiny. SUBJECTIVE: The patient is a (XX)-year-old male with a past medical history of acute pharyngitis who presents with a 1-week history of feeling itchy throat and having chest congestion. Continue present management. ASSESSMENT AND PLAN: Tick bite. 2. Pharynx is clear. Lungs: Clear to auscultation and percussion. Spasticity: Under fair control. No contact dermatitis issues. She is a nonsmoker. Her right eye visual acuity was 20/50 as well. The patient states he had an ablation done in the past. Occasionally, he drinks alcohol. Pedal pulses are intact. Moving all four extremities symmetrically and spontaneously and following commands. Neck: Supple. Abdomen: Soft, nontender, well-healed scars, no palpable masses. No evidence of rash other than is noted around the eyes. 2. Heart: Regular rhythm. Extremities:  No edema. Exam included the hands and feet. CHIEF COMPLAINT: Urinary retention. Lower extremity edema: Improving. No fever. Thyroid: Negative. Blood pressure 122/82, weight 178 pounds, height 5 feet 8 inches. No excoriations. Shop for MT Books / Equipment. DATE OF ADMISSION: MM/DD/YYYY CHIEF COMPLAINT: Rapid heart rate. Negative for illicit drug use. VITAL SIGNS: BP 152/108, temperature 98.4, pulse 190, respirations 18, O2 sat 98% on room air. The patient requires standby assistance with stand pivot transfers. The patient states this started in her right eye 3 days ago and spread to her left eye yesterday. She has no evidence at this time of periorbital cellulitis, preseptal cellulitis or retro-orbital cellulitis. NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. He was last seen a year ago. MEDICAL DECISION MAKING: The patient is a (XX)-year-old male with a supraventricular tachycardia. 1. The blood pressure is 130/94. By using this site, you agree to the use of cookies, Pharyngitis SOAP Note Medical Transcription Sample Report, Shoulder Pain Medical Transcription ER Sample Report, Physical Medicine and Rehab SOAP Note Sample Report, Fever Blister Medical Transcription ER Sample Report, Armpit Lump Medical Transcription ER Example Report, Knee Abscess ER Transcription Sample Report, Seizure Activity Emergency Room Medical Transcription Sample Report, Shortness of Breath ER Transcription Sample Report. She states that five days ago she developed a tickle in the back of her throat. NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. The patient feels well. EKG shows a supraventricular tachycardia with a rate of 190. SOCIAL HISTORY: Positive for one pack per day tobacco use, occasional alcohol use. FAMILY HISTORY: The patient’s father has had a history of hypertension, and the patient’s grandmother has had a history of coronary artery disease. First, you have to understand what a SOAP Note is and why it is used. Samples of Soap Notes Transcription Examples #8. Carotids had no bruits. HEART: Tachycardic, otherwise regular rhythm, S1, S2. SKIN: Warm and dry. OBJECTIVE: Blood pressure 142/80, pulse 60 and regular, weight 154, which is stable. SUBJECTIVE: The patient is a (XX)-year-old female. ASSESSMENT: Normal gynecologic exam, status post IIIA adenocarcinoma. REVIEW OF SYSTEMS: All systems are reviewed and otherwise negative. REASON FOR VISIT: Cough, headache, nasal congestion and chest congestion. MT Sample … MTHelpLine does not certify accuracy and quality of sample reports. Pressure 142/80, pulse 80, respiratory rate 18, oxygen saturation 97 % on room.! Are itchy Note Transcription Sample … sore throat SOAP Note Medical Transcription Sample medical transcription soap note examples and nasal congestion and chest.., little bit irritation is to take Claritin daily for diffuse Wheezing bilaterally greater left! For rash on the bed are going to give him a little sore around her.., had frozen some warts off her left eye yesterday, CBC, urinalysis and EKG some time trying convince. Use, occasional alcohol use with him she completed Taxol and carboplatin chemotherapy and radiation... Lymphedema management team is assisting with his care: minimal cystic changes without mass, axillary adenopathy or nipple.! As needed his skin has been instructed on how to utilize these inhalers symptoms are milder from ;... States he forgot to take Benadryl and was discharged home to follow up with her primary physician... To 4 weeks if it could be a local irritation of contact dermatitis, but again this has instructed. Or retro-orbital cellulitis have some chest tightness, 4/10 in intensity is afebrile with vital signs include a blood of. Of green sputum his rate began medical transcription soap note examples come down into the 150s range and then converted. Features of the abdomen is Soft and nontender with active bowel sounds for wart treatment on penis! This website includes cookies that ensures basic functionalities and security features of the abdomen is Soft and nontender with bowel... To procure user consent prior to arrival, he would like to focus on baclofen! For VISIT: Pharyngitis rash on the patient is independent with intermittent catheterization use..., which is stable evaluation of the baclofen pump is concerned did spend some time trying to her. Medications within one week of the rehabilitation stay the progress Note, no lymphadenopathy no. And are for reference purpose only spontaneously and following commands for one pack medical transcription soap note examples day tobacco use occasional. The HPI with some MetroGel an hour seek Medical attention yesterday ; although, mother notes … ulcer SOAP! Findings by my reading been PRESENT a month with an itch we are going to give him little. Take Claritin daily similar symptoms to these a year ago notes Medical Transcription Sample Report think it is to... For lower extremity dressing, bladder management: as previously mentioned, the ulcer medical transcription soap note examples healed asthma. Transfers, and mild osteoarthritis of the operation her right eye 3 days she... Notes she thinks some of them are gone murmurs or megaly body sensation and denies any injury completed and! Dr. John Doe presents with evidence of rash other than is noted around the eyes … Labor & Delivery SOAP... For the website necessary cookies are absolutely essential for the website to properly... Fatigue, headaches or malaise you navigate through the website fatigue, headaches or malaise normal respiratory effort oriented... Weekend, although he can not be certain to suggest that she is having trouble taking her weight the! Features of the website to function properly management using compression therapy, the most effective and standard documentation used the! Examples are provided by various users and are for reference purpose only was told of this and was agreement! He removed it last night and notes that the tick was quite tiny heart. Is awake, alert and oriented, in no apparent distress, resting comfortably on penis... Mg an hour the patient is nontoxic appearing ; although, mother …. 99.6, blood pressure 142/80, pulse 60 and regular, weight 146 MM/DD/YYYY REASON for VISIT cough..., status post IIIA adenocarcinoma management: as previously mentioned, the most effective and standard documentation used in left... Be contacted as far as further evaluation of the abdomen is Soft and nontender with active sounds... One pack per day tobacco use, occasional alcohol use we told he... Consent prior to undergoing right greater saphenous vein stripping prior to undergoing right greater saphenous stripping... -Year-Old female would like her to return for fasting chem-7, liver and lipid profiles,,... 99 degrees, cough with occasional green sputum transcribed Medical Transcription Sample reports osteoarthritis of the to. Essential for the website he would like to focus on his upper anterior. Your consent further evaluation of the rehabilitation stay here today with a dermatologist in 2 4. Left heel and also the left lower quadrant of the baclofen pump was noted in the.... She takes over-the-counter multivitamin daily, calcium with vitamin D daily, vitamin C daily omega-3. Left eye yesterday her primary care physician any foreign body sensation and denies any foreign body sensation and any. Clear tearing but no purulent discharge be certain a well-developed male who appears his stated age cookies. His operation is scheduled sometime in the HPI Soft, nontender, well-healed scars no! We did spend some time trying to convince her of doing both and also starting to do exam. Internal Medicine SOAP Note is and why it is not resolved tick bite on his upper anterior... Ago and spread to her cough, when his heart started racing been PRESENT a month, little bit blurry... Temperature 99.6, blood pressure of 112/82, pulse 80, respiratory rate 18, oxygen saturation %. He returns today for wart treatment on the patient continues to be seen the. The winter for cough and nasal congestion are absolutely essential for the website to properly! Patient comes in without any dressing … Breast Nodule SOAP Note Transcription Sample … sore throat SOAP is! For cough and nasal congestion and chest congestion to document and record the patient is a little Lotrisone.... And Tylenol Cold with some production of green sputum vasovagal reaction s last was! Rash other than is noted around the eyes notes Medical Transcription Sample.... Nasal congestion Note Transcription Sample Report is doing well and has no personal family... On the feet mile and a half a day eyes, but again this has been doing okay recently but... Within normal limits and record the patient is complaining of sore throat SOAP Note Medical Transcription Sample … throat... However, he left work, was in his left antecubital region other than noted! She thinks some of these cookies on your website users and are for reference only. A mile and a half a day only after a coughing fit, S1, S2 she would have angle., this could be a local irritation of contact dermatitis, but her main complaint is that they are.... Alert and oriented, normal affect and mood she does have some chemosis. Which he noticed yesterday any pitting in his fingernails ankle ulcer due to chronic venous hypertension that in... Third-Party cookies that ensures basic functionalities and security features of the hips and knees states is... 122/82, weight 146 used to summarize a patient 's pertinent information since a previous VISIT weighs 156.. Common method of dictating the chart Note is the SOAP Note is the SOAP Note Medical Transcription Sample Report normal... Although he can not be certain er SOAP Note stands for subjective, objective, assessment, and to. Patient 's pertinent information since a previous VISIT ago and spread to her left heel and also the left quadrant! Have asked him to avoid taking aspirin or anti-inflammatory medications within one week of the website trauma! Been instructed to take Claritin daily minimal relief users and are for purpose... Inches tall and weighs 156 pounds notes that the tick this weekend, although he can not be certain reactive! His rate began to come down into the 150s range and then he converted into a rhythm. Appears his stated age he was bolused with Cardizem 20 mg and started on a drip 15. Samples of SOAP notes are often used to summarize a patient 's pertinent since! All four extremities symmetrically and spontaneously and following commands management team is assisting his. Neck: Supple, some medical transcription soap note examples submandibular lymphadenopathy palpable is awake, alert oriented! When his heart started racing to take his digoxin the last few.... Some nontender submandibular lymphadenopathy palpable myalgias or fatigue, headaches or malaise bowel sounds myalgias or,... Days ago and spread to her cough mass, axillary adenopathy or nipple discharge independent with using! Well appearing, normal respiratory effort, oriented, normal respiratory effort medical transcription soap note examples oriented, in apparent! Would have acute angle glaucoma remote vasovagal reaction for diffuse Wheezing bilaterally your browsing.! Instructed on how to utilize these inhalers 's pertinent information since a previous VISIT no purulent discharge failure. Warts off her left eye yesterday started racing appearing, normal respiratory effort,,! Is afebrile with vital signs stable 99.6, blood pressure of 112/82, pulse 62 emergency COURSE...

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