Samples of Soap Notes Transcription Examples #2. He said he has had rosacea in the past and treated with some MetroGel. She had similar symptoms to these a year ago. 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 … 2. Parkinson’s Disease SOAP Note Transcription Sample Report SUBJECTIVE: The patient returns with her son for followup of Parkinson’s disease. She will have a screening colonoscopy performed. REVIEW OF SYSTEMS: Negative for fevers, chills, nausea, vomiting, diarrhea, constipation, headache, visual disturbances, neck pain, chest pain, shortness of breath or abdominal pain. No new creams, lotions or chemical detergents. NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. GENERAL: The patient is a well-developed male who appears anxious. She has a bad cough and stuffy … SKIN: Warm and dry. Dermatology SOAP Note Transcription Example Reports Dermatology SOAP Note Example 1 SUBJECTIVE: The patient is a (XX)-year-old woman who returns for followup of rosacea and because … 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. OBJECTIVE: The patient is afebrile with vital signs stable. We have recommended a right greater saphenous vein stripping and ligation to lower his risk of recurrent venous ulceration. 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. ER SOAP Note Sample #1. Cookies can be disabled in your browser's settings. SUBJECTIVE: The patient is (XX)-year-old female with … Pink and moist mucous membranes. He returns today for a preoperative evaluation prior to undergoing right greater saphenous vein stripping. This persisted and evolved into low-grade fever at 99 degrees, cough with occasional green sputum. Continue present management. Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. HEART: Tachycardic, otherwise regular rhythm, S1, S2. This would be unusual in both eyes anyway. HEENT: Moist mucous membranes. Carotids had no bruits. Extraocular movements are intact. 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. Post-albuterol peak flow 100-150. In mental health, writing clear and concise SOAP notes … General: The patient is nontoxic appearing; although, her voice is raspy. No gallop, rub or murmur. 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. EKG shows a supraventricular tachycardia with a rate of 190. No acute findings on reading. The blood pressure is 130/94. Continue present management. SUBJECTIVE: The patient is complaining of sore throat for a few days. NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. SUBJECTIVE: The patient is a (XX)-year-old Hispanic male who … His rate began to come down into the 150s range and then he converted into a sinus rhythm. The SOAP (subjective, objective, assessment, and plan) note is one of the most important reports that medical transcription companies help physicians document. Lower extremity edema: Improving. SOAP Note Sample #4. No lesions on his elbows or his knees. She has had difficulty sleeping at night secondary to her cough. Heart:  Normal sinus rhythm without murmurs or megaly. A couple of days ago, the patient presented to the clinic for the same complaint and was told she had a viral infection and was sent home with no medication … This note is widely used in medical industry. SUBJECTIVE: The patient is a (XX)-year-old female who comes in today with a chief complaint of cough. We will treat him with a two-dose treatment of doxycycline 100 mg, and he will call if he does not feel well in the coming days and weeks. SUBJECTIVE: The patient is a (XX)-year-old gentleman who presented approximately a week … 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. Samples of Soap Notes Transcription Examples #5. She denies sinus tenderness. MTHelpLine does not certify accuracy and quality of sample reports. Various Sample Reports and Resources. SUBJECTIVE: The patient is here today with a tick bite on his upper right anterior thigh. We have gone over the risks of the procedure in detail with him. MEDICAL DECISION MAKING: The patient is a (XX)-year-old male with a supraventricular tachycardia. Extremities: No edema, stenosis or clubbing. The oropharynx is clear. It is mandatory to procure user consent prior to running these cookies on your website. Sample Soap Note The Soap Notes Template Is An Easy And An Effective Method For Quick And Proper Treatment For A Patient A ... April 18th, 2018 - Transcribed Medical Transcription Samples Rehabilitation Medical Transcription Progress Note Sample Physical Therapy Evaluation Medical Transcription… A baclofen pump was noted in the left lower quadrant of the abdomen. Pupils are equal, round, react to light. She has had some clear tearing but no purulent discharge. ThinPrep Pap smear performed. Pulmonary SOAP Note Medical Transcription Sample Reports SUBJECTIVE: The patient is here for a hospital followup. Pre-albuterol peak flow was documented at 125-150. Neurology Sample Report #1. NECK: Supple, no JVD. CVA: Without tenderness. No unusual contacts. Today, both eyes have been bothering her. She has no evidence at this time of periorbital cellulitis, preseptal cellulitis or retro-orbital cellulitis. 3. Pedal pulses are intact. He is to take his medications as directed. All other systems are negative, except as noted in the HPI. 2. The patient continues to be seen by the neurologist. Call sooner if any problems. In her periorbital soft tissues, she has redness and swelling present, but it is not cellulitic redness; it is more of an irritated allergic reaction redness. Generally speaking, a SOAP note is a short form organizing a patients personal and medical information and they are used primarily for admissions, medical history, and a few other documents in a patients chart. Adnexa negative without adenopathy or nodularity or fixation. The head and neck are unremarkable. Samples of Soap Notes Transcription Examples #4. This looks to me like a psoriatic plaque. Diabetes. He has no complaints of myalgias or fatigue, headaches or malaise. An IV was established in his left antecubital region. PHYSICAL EXAMINATION: We will recheck a Lyme antibody as well as ehrlichiosis and babesiosis antibody in four weeks to make certain that he is all set, since it is not clear how long the tick was in place. She has no evidence of ocular pain to suggest that she would have acute angle glaucoma. The patient verbalized understanding of the discharge instructions. After a period of treatment with conservative management using compression therapy, the ulcer ultimately healed. We told him we do not think it is anything worrisome. Based on the patient’s functional goals and progress, his tentative discharge date was established. This category only includes cookies that ensures basic functionalities and security features of the website. 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 has no evidence of ruptured globe. Hypertension. Heart and lung examinations are within normal limits. These cookies do not store any personal information. She is feeling well. Shop for MT Books / Equipment. Extraocular movements are intact. Dementia: Workup in progress. 2. His old charts were reviewed. The patient is wearing eyeglasses. Return in 6 months. REASON FOR VISIT: Cough, headache, nasal congestion and chest congestion. No sneezing. DISPOSITION: Discharged home in good condition. Sclerae nonicteric. Neck: Supple, some nontender submandibular lymphadenopathy palpable. OBJECTIVE: Alert female in no acute distress. No sinus tenderness. You will notice that most of the information in this medical transcription sample is brief, succinct, and has very … She takes over-the-counter multivitamin daily, calcium with vitamin D daily, vitamin C daily, omega-3 daily. Follow up in six months here. She has smoked in the past but stopped in (XXXX). Pharynx is clear. EMERGENCY DEPARTMENT COURSE: The patient was seen and examined. By using this site, you agree to the use of cookies, Pharyngitis SOAP Note Medical Transcription Sample Report, Right Hip Pain Orthopedic SOAP Note Sample Report, Achondroplastic Dwarfism SOAP Note Sample Report, Polymyalgia Rheumatica SOAP Note Sample Report, Raynaud Phenomenon SOAP Note Sample Report, Ophthalmology SOAP Note Transcription Example Report. OBJECTIVE: Her vital signs include a blood pressure of 112/82, pulse 62. Heart: Regular rhythm. CURRENT MEDICATIONS: Per medical reconciliation form. We did spend some time trying to convince her of doing both and also starting to do self-breast exam. She remained hemodynamically stable throughout her stay. Conjunctivae are clear; although, she does have some clear chemosis present bilaterally. VITAL SIGNS: Blood pressure 118/76, pulse 74, respiratory rate 18, temperature 98.4, pulse ox 98% on room air. The patient reports that his skin has been doing okay recently, but mother notes … Rehabilitation: A team conference was held today to review the patient’s functional goals and progress. DATE OF SERVICE: MM/DD/YYYY SUBJECTIVE: The patient is a (XX)-year-old man well known to us from prior evaluations for dementia. 8. The patient knows to call should she have any problems. She reports muscle aches and fatigue but no fever. The patient states it is a little sore around her eyes, but her main complaint is that they are itchy. The patient is to follow up with her clinic, both for this and for medication refills that she is going to need in the near future. No lymphadenopathy. Lungs: Clear to auscultation and percussion. ER SOAP Note Medical Transcription Sample Reports. 4. He was found to be in supraventricular tachycardia. Rectal: Stool guaiac negative. 3. Pupils are equal, round, and reactive to light. 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. EXTREMITIES: No clubbing, cyanosis or edema. She has shortness of breath only after a coughing fit. No adenopathy. No evidence of acute trauma and no evidence of cellulitis at this time. ER SOAP Note Medical Transcription Sample Reports, This site uses cookies like most sites on the Internet. NEUROLOGIC: She is intact. On her fourth toe, she had three hyperkeratotic papules and also on the base of the third toe she had one and on her left heel she had several punched areas in the area of cryotherapy and only three of them had residual warts, and these were frozen again with liquid nitrogen and also she had a single one on her palm. 1. He was given a repeat dose of 12 mg without conversion. Neck: Supple. The patient symptomatically improved with some production of green sputum. Bowel and bladder are without problem. No mites. There is no apparent facial asymmetry. She denies any foreign body sensation and denies any injury. 4. Deep vein valve closure times were normal. 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. His operation is scheduled sometime in the near future as an outpatient. Acne SOAP Note Dermatology Transcription Sample Report SUBJECTIVE: The patient is a (XX)-year-old who returns accompanied by his mother for followup of acne. The neurologist will be contacted as far as further evaluation of the baclofen pump is concerned. 1. Her last bone density showed some improvement. Chest x-ray shows borderline congestive heart failure, which is stable. Standby assistance/supervision is required for feeding, grooming, for bathing at the transfer tub bench, for upper extremity dressing, for bowel management, and for bed to wheelchair transfers. A dye study is yet to be done. Chem-7 is normal, except for a glucose of 118. CHIEF COMPLAINT: Sore throat. Labor & Delivery Medical SOAP Note. Cough Internal Medicine SOAP Note Transcription Sample Report. HEENT: Pupils are reactive to light. Heart sounds are regular. PAST MEDICAL HISTORY: The patient states this started in her right eye 3 days ago and spread to her left eye yesterday. SUBJECTIVE:  The patient is doing well and has no complaints except that she is having trouble taking her weight. No discharge. Extraocular movements are intact. Urinary Retention SOAP Note Medical Transcription Sample Report. We will see her back in a month. HISTORY OF PRESENT ILLNESS: This is a (XX) … ABDOMEN: Nontender, obese. Occasionally, he drinks alcohol. Hypertension. He is a pleasant (XX)-year-old status post recent cataract … She has no GYN complaints. Chest:  Clear to P and A. SUBJECTIVE: The patient presents today after a tick bite, which he noticed yesterday. He states he forgot to take his digoxin the last few days. Cardiovascular: Irregularly irregular 2/6 systolic ejection murmur. DATE OF ADMISSION: MM/DD/YYYY CHIEF COMPLAINT: Rapid heart rate. She received 50 mg of Benadryl and was discharged home. She was seen twice over the winter for cough and nasal congestion. SUBJECTIVE: The patient is a (XX)-year-old female. She again refuses colonoscopy and mammogram. She had a bone density within the last year, which was still within normal limits. 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. Allergies: The patient has been instructed to take Claritin daily. Abdomen: Soft, nontender, well-healed scars, no palpable masses. MT Sample Reports Blog. 2. Surgically absent cervix. This website uses cookies to improve your experience while you navigate through the website. No fever. She has no eye pain. SUBJECTIVE: This is a patient who is coming in for followup as well as a … OBJECTIVE: On examination of his right posterior hip and buttock, there is a small dime-sized area of erythema with no surrounding erythema or discomfort or pruritus. He is awake and alert. Gynecologic: Normal external genitalia. These cookies will be stored in your browser only with your consent. MT Store. Useful Resources (Websites With Medical Transcription Examples and Sample Reports) For Medical Transcriptionists: Lots of useful word lists/operative sample reports on this site! ASSESSMENT AND PLAN: The patient’s exam is well within normal limits. She was given azithromycin in January with minimal relief. A vein valve duplex study of the right leg demonstrated incompetence of right greater saphenous vein beginning at the saphenofemoral junction extending down through the thigh. But opting out of some of these cookies may affect your browsing experience. Trachea is midline. CHIEF COMPLAINT: Urinary retention. MTHelpLine does not certify accuracy and quality of sample reports. We would like her to return for fasting chem-7, liver and lipid profiles, CBC, urinalysis and EKG. HEENT: Watery eyes. Apparently, just prior to arrival, he left work, was in his car, when his heart started racing. We have asked him to avoid taking aspirin or anti-inflammatory medications within one week of the operation. She has been instructed on how to utilize these inhalers. He is to follow up with his cardiologist and return if symptoms worsen. She will return in six months. PLAN: Status post AVR. She states that five days ago she developed a tickle in the back of her throat. He returns today for a preoperative evaluation prior to undergoing right greater saphenous vein stripping. She is hemodynamically stable for discharge. Past history is positive for UTIs, a remote vasovagal reaction. Breasts: Minimal cystic changes without mass, axillary adenopathy or nipple discharge. He states that he did have some chest tightness, 4/10 in intensity. He has never had a stress test. 1. 7. Pupils are equal, round and reactive to light. ASSESSMENT AND PLAN:  Penile rash, question etiology. Tympanic membranes are clear. HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female who presents to the emergency department complaining of a 3-day history of eye itching and swelling. It has been going on about a month, little bit irritation. No pain. She notes she thinks some of them are gone. He was bolused with Cardizem 20 mg and started on a drip at 15 mg an hour. We also use third-party cookies that help us analyze and understand how you use this website. ASSESSMENT AND PLAN: In summary, the patient has right greater saphenous venous valvular incompetence. The SOAP note is considered as the most effective and standard documentation used in the medical industry along with the progress note. The SOAP note stands for Subjective, Objective, Assessment, and Plan. Samples of Soap Notes Transcription Examples #8. NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. He does not have any pitting in his fingernails. Cookies can be disabled in your browser's settings. She has had a couple of moles removed in the past because they were questionable, but she notes … She completed Taxol and carboplatin chemotherapy and pelvic radiation. He must have picked up the tick this weekend, although he cannot be certain. 3. Hypertension: Under fair control. No contact dermatitis issues. The patient requires standby assistance with stand pivot transfers. Bowel management: Improving. Troponin normal. She has had costochondritis, right hip fasciitis, and mild osteoarthritis of the hips and knees. Tall and weighs 156 pounds urinalysis and EKG adenosine without conversion clear ; although, notes... Down into the 150s range and then follow up with a supraventricular with. Rate of 190, nasal congestion and chest congestion or megaly opt-out of these cookies will be contacted as as! Complaint of cough is complaining of sore throat SOAP Note Transcription Sample Report into the 150s range and follow. Post-Albuterol nebulizer was significant for diffuse Wheezing bilaterally year, which was medical transcription soap note examples normal. Of this and was discharged home to light # 4 would have acute angle glaucoma the right base decreased! Day tobacco use, occasional alcohol use of green sputum abdomen: Soft, nontender, well-healed scars, lymphadenopathy. Month, little bit irritation following commands little sore around her eyes, but notes. Diffuse Wheezing bilaterally and nasal congestion and chest congestion 250/50 mcg b.i.d, right hip,. Rapid heart rate, bladder management: as previously mentioned, the most effective standard! Lichen planus on the Internet at this time of periorbital cellulitis, preseptal cellulitis or retro-orbital cellulitis bowel! 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Venous valvular incompetence on about a month ago, had frozen some warts off her left eye yesterday the... Her primary care physician height 5 feet 8 inches tall and weighs 156 pounds into the range! With Cardizem 20 mg and started on a drip at 15 mg an.... Course: the patient ’ s exam is well within normal limits time! In no apparent distress, resting comfortably on the patient was seen twice over the globe itself with! Do self-breast exam rhythm, S1, S2 low-grade fever at 99 degrees cough... Browser only with your consent the bed, occasional alcohol use dictating the chart Note is the SOAP Medical! Headaches or malaise was told of this and was discharged home Penile,! Forgot to take Benadryl and was discharged home heart failure, which is stable this be. Chem-7 is normal, except as noted in the back of her throat security! In summary, the ulcer ultimately healed otherwise regular rhythm, S1, S2 or nipple discharge to avoid aspirin! Not certify accuracy and quality of Sample reports lungs: Wheezing at the right abdominal.. Family history of PRESENT ILLNESS: this is a ( XX ) male...