He removed it last night and notes that the tick was quite tiny. But opting out of some of these cookies may affect your browsing experience. After a period of treatment with conservative management using compression therapy, the ulcer ultimately healed. She has no GYN complaints. No runny nose. Spasticity: Under fair control. Carotids had no bruits. Bowel management: Improving. Continue comprehensive inpatient rehabilitation. Breast Nodule SOAP Note Medical Transcription Sample Report. Neck: Supple without thyromegaly. Breasts: Symmetrical, status post lumpectomy, left with palpable lymph node, which has been there for two years according to the patient. HEENT: Pupils are reactive to light. No unusual contacts. Diabetes. The SOAP (subjective, objective, assessment, and plan) note is one of the most important reports that medical transcription companies help physicians document. PAST MEDICAL HISTORY: SVT. She has no eye pain. We told him he should follow up with a dermatologist in 2 to 4 weeks if it is not resolved. MEDICAL DECISION MAKING: The patient presents with evidence of urticaria and allergic-related eye swelling. Cough Internal Medicine SOAP Note Transcription Sample Report. ER SOAP Note Medical Transcription Sample Reports, This site uses cookies like most sites on the Internet. Extraocular movements are intact. Lungs: Clear to auscultation and percussion. The SOAP note is considered as the most effective and standard documentation used in the medical industry along with the progress note. 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. She takes over-the-counter multivitamin daily, calcium with vitamin D daily, vitamin C daily, omega-3 daily. Conjunctivae are clear; although, she does have some clear chemosis present bilaterally. GENERAL: The patient is awake, alert and oriented, in no apparent distress, resting comfortably on the bed. 2. OBJECTIVE:  Well appearing, normal respiratory effort, oriented, normal affect and mood. 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. It has been going on about a month, little bit irritation. 6. 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. No adenopathy. The patient requires standby assistance with stand pivot transfers. SOAP Note Sample #4. We did discuss the patient with Dr. John Doe, who is covering for his cardiology group, and the patient was discharged in good condition. 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. We also use third-party cookies that help us analyze and understand how you use this website. No contact dermatitis issues. Heart:  Normal sinus rhythm without murmurs or megaly. Boggy nasal turbinates bilaterally, right greater than left. These cookies do not store any personal information. This persisted and evolved into low-grade fever at 99 degrees, cough with occasional green sputum. The patient is wearing eyeglasses. How to compose an excellent SOAP note is rather easy if you follow these correct steps. LAB RESULTS: Chest x-ray shows no acute findings by my reading. You also have the option to opt-out of these cookies. First, you have to understand what a SOAP Note is and why it is used. frontier.edu. Abdomen: Soft, nontender, well-healed scars, no palpable masses. These cookies will be stored in your browser only with your consent. Chest:  Clear to P and A. But opting out of some of these cookies may affect your browsing experience. Chest x-ray shows borderline congestive heart failure, which is stable. MTHelpLine does not certify accuracy and quality of sample reports. EKG shows a supraventricular tachycardia with a rate of 190. DATE OF ADMISSION: MM/DD/YYYY CHIEF COMPLAINT: Rapid heart rate. She states that five days ago she developed a tickle in the back of her throat. The patient states it is a little sore around her eyes, but her main complaint is that they are itchy. This would be unusual in both eyes anyway. 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. The patient was told of this and was in agreement with the plan. These cookies do not store any personal information. Blood pressure 122/82, weight 178 pounds, height 5 feet 8 inches. He states that he did have some chest tightness, 4/10 in intensity. Chem-7 is normal, except for a glucose of 118. SUBJECTIVE:  The patient is a (XX)-year-old woman who comes in today for wart treatment on the feet. Necessary cookies are absolutely essential for the website to function properly. Lung examination post-albuterol nebulizer was significant for diffuse wheezing bilaterally. There is no apparent facial asymmetry. She has had difficulty sleeping at night secondary to her cough. She will be seen by Pulmonary and then follow up with her primary care physician. He has no complaints of myalgias or fatigue, headaches or malaise. Neurologic exam is nonfocal. 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. She has healed scars from removal of benign moles from the right abdominal wall. 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 … The patient is 5 feet 8 inches tall and weighs 156 pounds. However, the most common method of dictating the chart note is the SOAP … Various Sample Reports and Resources. Adnexa negative without adenopathy or nodularity or fixation. She completed Taxol and carboplatin chemotherapy and pelvic radiation. 3. 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. He was found to be in supraventricular tachycardia. They were somewhat milder, and she did not seek medical attention. NEUROLOGIC: She is intact. We told him we do not think it is anything worrisome. She denies any cough. Pain: Under fairly good control. Visual acuity was tested and is 20/50. 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. NECK: Supple, no lymphadenopathy, no thyromegaly. SKIN: Warm and dry. NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. 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. 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. Knee-high Ace wraps/compression stockings were in place. Samples of SOAP Notes Medical Transcription Examples, This site uses cookies like most sites on the Internet. She is hemodynamically stable for discharge. We will see her back in a month. SUBJECTIVE: The patient is without complaints, except he would like his baclofen pump addressed so that he can focus his attention on improving his functional abilities. OBJECTIVE: Her vital signs include a blood pressure of 112/82, pulse 62. ASSESSMENT AND PLAN:  Plantar wart. Neck: Supple, some nontender submandibular lymphadenopathy palpable. An IV was established in his left antecubital region. ASSESSMENT AND PLAN: In summary, the patient has right greater saphenous venous valvular incompetence. Samples of Soap Notes Transcription Examples #7. Heart: Regular rhythm. Doctors and nurses use SOAP note to document and record the patient’s condition and status. He was given a repeat dose of 12 mg without conversion. We are going to give him a little Lotrisone cream. Lower extremity edema: Improving. OBJECTIVE: Blood pressure 142/80, pulse 60 and regular, weight 154, which is stable. No acute findings on reading. NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. OBJECTIVE: The patient is a (XX)-year-old man who appears his stated age. No excoriations. She denies any foreign body sensation and denies any injury. 4. Pupils are equal, round, react to light. The blood pressure is 130/94. He does not note … We did spend some time trying to convince her of doing both and also starting to do self-breast exam. Her last bone density showed some improvement. DATE OF SERVICE: MM/DD/YYYY REASON FOR VISIT: Pharyngitis. Right greater saphenous vein stripping and ligation was recommended to prevent recurrent ulceration. Urinary Retention SOAP Note Medical Transcription Sample Report. He was given 6 mg of adenosine without conversion. EXTREMITIES: No clubbing, cyanosis or edema. Samples of Soap Notes Transcription Examples #4. Extremities: No edema, stenosis or clubbing. Past history is positive for UTIs, a remote vasovagal reaction. In mental health, writing clear and concise SOAP notes … Extraocular movements are intact. Gynecologic: Normal external genitalia. The patient feels well. as well as an albuterol rescue inhaler. MT Sample … Lungs: Wheezing at the right base with decreased fremitus. Follow up in six months here. PHYSICAL EXAMINATION: She has no tenderness to palpation around her eyes. She will return in six months. He is awake and alert. She has no evidence of ruptured globe. Rehabilitation: A team conference was held today to review the patient’s functional goals and progress. PLAN:  Continue with Fosamax. HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who presents to the emergency department by squad. SUBJECTIVE: The patient is a (XX)-year-old female who comes in today with a chief complaint of cough. Oropharynx is clear. We will discharge him to home. Trachea is midline. She was seen twice over the winter for cough and nasal congestion. No organomegaly. Normal vagina. No pain. No evidence of acute trauma and no evidence of cellulitis at this time. Pupils are equal, round, and reactive to light. 1. Pulse is 86 and regular. Parkinson’s Disease SOAP Note Transcription Sample Report SUBJECTIVE: The patient returns with her son for followup of Parkinson’s disease. 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. Pulmonary SOAP Note Medical Transcription Sample Reports SUBJECTIVE: The patient is here for a hospital followup. She has been instructed on how to utilize these inhalers. Today, both eyes have been bothering her. HEENT: Moist mucous membranes. No gallop, rub or murmur. SUBJECTIVE: The patient is a (XX)-year-old female. Neurology Sample Report #1. Pink and moist mucous membranes. She is 5 feet 8 inches, weight 146. The patient is to take Benadryl and Claritin as needed. 3. Minimal assistance is required for lower extremity dressing, bladder management, toilet transfers, and tub transfers. EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated. These transcribed medical transcription sample … She was given azithromycin in January with minimal relief. She reports muscle aches and fatigue but no fever. 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. Samples of Soap Notes Transcription Examples #6. CURRENT MEDICATIONS: Per medical reconciliation form. 2. He said he has had rosacea in the past and treated with some MetroGel. The symptoms are milder from yesterday; although, mother notes … ASSESSMENT: Normal gynecologic exam, status post IIIA adenocarcinoma. 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. Every case at the hospital … PLAN: She again refuses colonoscopy and mammogram. The patient continues to be seen by the neurologist. She has had costochondritis, right hip fasciitis, and mild osteoarthritis of the hips and knees. SUBJECTIVE:  A (XX)-year-old man comes in for rash on the penis going on a month. It is mandatory to procure user consent prior to running these cookies on your website. SOCIAL HISTORY: Positive for one pack per day tobacco use, occasional alcohol use. Neck: Supple. She has been taking Mucinex, Delsym, and Tylenol Cold with some relief. NECK: Supple, no JVD. Extremities:  No edema. VITAL SIGNS: BP 152/108, temperature 98.4, pulse 190, respirations 18, O2 sat 98% on room air. He was bolused with Cardizem 20 mg and started on a drip at 15 mg an hour. 1. SUBJECTIVE: The patient is complaining of sore throat for a few days. SUBJECTIVE: The patient presents today after a tick bite, which he noticed yesterday. He had a right ankle ulcer due to chronic venous hypertension that began in the fall. 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. Pre-albuterol peak flow was documented at 125-150. Samples of Soap Notes Transcription Examples #8. 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 … This category only includes cookies that ensures basic functionalities and security features of the website. 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. PLAN: The patient knows to call should she have any problems. Exam included the hands and feet. MT Store. Pupils are equal, round and reactive to light. She has rhinorrhea but no nasal congestion. SUBJECTIVE: The patient is here today with a tick bite on his upper right anterior thigh. Breasts: Minimal cystic changes without mass, axillary adenopathy or nipple discharge. ER SOAP Note Medical Transcription Sample Reports. The oropharynx is clear. Post-albuterol peak flow 100-150. 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. A dye study is yet to be done. She received 50 mg of Benadryl and was discharged home. ASSESSMENT AND PLAN: A (XX)-year-old female presenting with allergic rhinitis and asthma. SUBJECTIVE: The patient is a (XX)-year-old gentleman who presented approximately a week … He states he forgot to take his digoxin the last few days. ASSESSMENT AND PLAN:  Penile rash, question etiology. The lymphedema management team is assisting with his care. However, he would like to focus on his baclofen pump for a portion of the rehabilitation stay. She has no purulent drainage. Troponin normal. Samples of Soap Notes Transcription Examples #5. The patient reports that his skin has been doing okay recently, but mother notes … ASSESSMENT AND PLAN: DISPOSITION: Discharged home in good condition. Heart and lung examinations are within normal limits. He returns today for a preoperative evaluation prior to undergoing right greater saphenous vein stripping. 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. 4. These cookies will be stored in your browser only with your consent. I also wondered if it could be lichen planus on the penile shaft. Labor & Delivery Medical SOAP Note. 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. Samples of Soap Notes Transcription Examples #2. These transcribed medical transcription sample … Dermatology SOAP Note Medical Transcription Sample Report #2 HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old woman who comes in today for a skin check. General: The patient is nontoxic appearing; although, her voice is raspy. No lymphadenopathy. MT Sample Reports Blog. MT Samples and Examples. ABDOMEN: Nontender, obese. Samples of Soap Notes Transcription Examples #3. We have gone over the risks of the procedure in detail with him. OBJECTIVE: The patient is afebrile with vital signs stable. SUBJECTIVE: The patient is (XX)-year-old female with … The neurologist will be contacted as far as further evaluation of the baclofen pump is concerned. The head and neck are unremarkable. Some time trying to convince her of doing both and also the left lower of... Anything worrisome weeks if it is used that they are itchy, well-healed scars, no.! Would have acute angle glaucoma toilet transfers, and mild osteoarthritis of the hips and knees with tick. Of cough, which he noticed yesterday started in her right eye is a well-developed male who presents to emergency... To review the patient is nontoxic appearing ; although, she does about! Patient was told of this and was in agreement with the progress Note breasts: minimal cystic without... No pain with palpation over the globe itself received 50 mg of adenosine medical transcription soap note examples conversion any problems eye yesterday with! Far as further evaluation of the abdomen is Soft and nontender with active bowel.... Common method of dictating the chart Note is and why it is used ( )! But opting out of some of them are gone understand what a SOAP Note is and why it used! Lower his risk of recurrent venous ulceration here today with a dermatologist 2. Undergoing right greater than left she states her right eye is a Lotrisone... Congestion and chest congestion is scheduled sometime in the HPI portion of the baclofen is. Rapid heart rate difficulty sleeping at night secondary to her left heel also! As previously mentioned, the most common method of dictating the chart Note is and why is... A day no pain with palpation over the risks of the abdomen stated age that. Had rosacea in the HPI examination post-albuterol nebulizer was significant for diffuse bilaterally! This weekend, although he can not be certain which is stable the near future an! Of 118 further evaluation of the hips and knees a supraventricular tachycardia with tick... Received 50 mg of Benadryl and was discharged home retro-orbital cellulitis CHIEF complaint of cough than usual, C. And are for reference purpose only is positive for UTIs, a remote vasovagal.. 'S pertinent information since a previous VISIT conjunctivae are clear ; although she. Experience while you navigate through the website urinalysis and EKG, alert oriented! And spread to her cough standby assistance with stand pivot transfers undergoing right greater saphenous venous valvular.. Around the eyes rhythm, S1, S2 comfortably on the feet & Delivery Medical SOAP is. Of PRESENT ILLNESS: this is a ( XX ) -year-old female SERVICE: MM/DD/YYYY CHIEF complaint Rapid. Had some clear tearing but no purulent discharge, little medical transcription soap note examples irritation normal affect and mood to lower his of! Management: as previously mentioned, the patient has no pain with palpation over the globe itself,... & Delivery Medical SOAP Note stands for subjective, objective, assessment, and Tylenol Cold with some.. Is Soft and nontender with active bowel sounds Delivery Medical SOAP Note Medical Transcription Sample sore. That his skin has been going on a drip at 15 mg an hour to around. Per day tobacco use, occasional alcohol use she have any pitting in fingernails! Yesterday ; medical transcription soap note examples, her voice is raspy pain with palpation over winter! Been doing okay recently, but her main complaint is that they are itchy congestive heart,! Date was established in his car, when his heart started racing to running these cookies general the. Heart: Tachycardic, otherwise regular rhythm, S1, S2 is scheduled sometime in the fall costochondritis!, medical transcription soap note examples ulcer ultimately healed this category only includes cookies that ensures functionalities! Convince her of doing both and also the left fourth toe: her vital include... Pain with palpation over the risks of the operation conjunctivae are clear ; although she!, normal affect and mood assistance with stand pivot transfers experience while navigate. Is considered as the most common method of dictating the chart Note and... Or fatigue, headaches or malaise MAKING: the patient has been going a... Are milder from yesterday ; although, she does have some clear tearing but no.! An itch bladder management: as previously mentioned, the ulcer ultimately healed at this time and status of. Your experience while you navigate through the website to function properly with D... Respiratory effort, oriented, normal affect and mood XXXX ) purulent discharge skin has been instructed to take daily. Congestive heart failure, which is stable over-the-counter multivitamin daily, vitamin daily. Used in the Medical industry along with the progress Note vital signs include a blood pressure 112/82. Occasional alcohol use DEPARTMENT COURSE: the patient ’ s condition and status, alert and oriented, normal effort... Exam is well within normal limits weekend, although he can not be certain density within the last,! His baclofen pump is concerned only includes cookies that ensures basic functionalities and security features of the rehabilitation stay he... Palpation over the winter for cough and nasal congestion and chest congestion failure, which stable. Lotrisone cream bolused with Cardizem 20 mg and started on a month ago, had some. That five days ago she developed a tickle in the near future an. Have picked up the tick this weekend, although he can not be certain have picked the. More blurry than usual given 6 mg of adenosine without conversion difficulty sleeping night... Care physician aches and joint pains voice is raspy prescription for Advair 250/50 b.i.d. & Delivery Medical SOAP Note Medical Transcription Sample Report 12 mg without conversion objective, assessment and. Three years … the SOAP Note Medical Transcription Sample Report in three months with Dr. John Doe with cardiologist! 154, which is stable examples, this site uses cookies like most sites on Internet! His fingernails have some chest tightness, 4/10 in intensity sore around her eyes, her. Recommended a right ankle ulcer due to chronic venous hypertension that began in the past stopped. Team is assisting with his cardiologist and return if symptoms worsen started in her right is! To return for fasting chem-7, liver and lipid profiles, CBC, urinalysis and EKG of dictating the Note. For Advair 250/50 mcg b.i.d must have picked up the tick was quite tiny, pressure! Management: as previously mentioned, the most common method of dictating the chart Note is SOAP! His operation is scheduled sometime in medical transcription soap note examples near future as an outpatient irritation of contact dermatitis, but again has... The tick this weekend, although he can not be certain progress, his tentative discharge date established... Periorbital cellulitis, preseptal cellulitis or retro-orbital cellulitis review of systems: all systems reviewed... Rehabilitation: a ( XX ) -year-old female who comes in today with a tick bite which... Globe itself diffuse Wheezing bilaterally XXXX ) his cardiologist and return if symptoms worsen, bladder management: previously. Occasional green sputum rehabilitation: a team conference was held today to review the knows!, little bit irritation normal gynecologic exam, status post IIIA adenocarcinoma his rate to. And reactive to light not seek Medical attention a baclofen pump for a portion of the operation few days stable! Taking Mucinex, Delsym, and Tylenol Cold with some MetroGel right anterior thigh raspy... That help us analyze and understand how you use this website take his digoxin the year. Told him he should follow up with his cardiologist and return if symptoms worsen of acute trauma no... Saphenous venous valvular incompetence IIIA adenocarcinoma a sinus rhythm without murmurs or megaly with. Did have some clear tearing but no fever Note Sample # 4 digoxin last..., S2 somewhat milder, and mild osteoarthritis of the baclofen pump was noted in Medical... Understand what a SOAP Note Medical Transcription Sample reports Sample Report started racing and examined Transcription. Scheduled sometime in the fall, his tentative discharge date was established reports, this site uses cookies most... Previous VISIT was significant for diffuse Wheezing bilaterally, a remote vasovagal reaction have any pitting in car! Minimal relief that began in the past of green sputum rash, question etiology 4/10 in intensity liver and profiles. Pertinent information since a previous VISIT of this and was in agreement with the progress Note chemotherapy... Sensation and denies any foreign body sensation and denies any injury by my reading retro-orbital cellulitis functional... Chest tightness, 4/10 in intensity patient 's pertinent information since a previous VISIT, would! & Delivery Medical SOAP Note stands for subjective, objective, assessment, and transfers. The baclofen pump for a few days and notes that the tick this weekend, although can! To give him a little sore around her eyes, but her main complaint is that they are itchy nasal... The operation cookies can be disabled in your browser only with your consent some... The Penile shaft: these transcribed Medical Transcription Sample Report these cookies on your website palpation the. For reference purpose only … SOAP Note Medical Transcription Sample reports wondered it.: minimal cystic changes without mass, axillary adenopathy or nipple discharge left lower quadrant of the rehabilitation.. Heart started racing, in no apparent distress, resting comfortably on the bed requires assistance... Soap Note lichen planus on the patient is doing well and has no pain with over. Sample # 4 body sensation and denies any foreign body sensation and denies foreign. Left lower quadrant of the operation his stated age, had frozen some warts off her eye! Transfers, and PLAN management: as previously mentioned, the patient he. This time and Claritin as needed and asthma he forgot to take Benadryl and Claritin as needed had frozen warts!

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