ASSESSMENT AND PLAN:  Penile rash, question etiology. She has no evidence at this time of periorbital cellulitis, preseptal cellulitis or retro-orbital cellulitis. No excoriations. Lower extremity edema: Improving. EXTREMITIES: No clubbing, cyanosis or edema. SUBJECTIVE: The patient is here today with a tick bite on his upper right anterior thigh. Urinary Retention SOAP Note Medical Transcription Sample Report. CHIEF COMPLAINT: Urinary retention. PLAN: Cookies can be disabled in your browser's settings. The patient is wearing eyeglasses. They were somewhat milder, and she did not seek medical attention. Pacemaker in place. Spasticity: Under fair control. He was bolused with Cardizem 20 mg and started on a drip at 15 mg an hour. 6. 3. In the interim, we increased her Sinemet to 25/100 mg 1-1/2 … He states that he did have some chest tightness, 4/10 in intensity. Lungs: Clear to auscultation and percussion. Breasts: Symmetrical, status post lumpectomy, left with palpable lymph node, which has been there for two years according to the patient. She has rhinorrhea but no nasal congestion. Trachea is midline. 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. Soap notes are often used to summarize a patient's pertinent information since a previous visit. He was last seen a year ago. DATE OF SERVICE: MM/DD/YYYY REASON FOR VISIT: Pharyngitis. The SOAP note is considered as the most effective and standard documentation used in the medical industry along with the progress note. SUBJECTIVE: This is a patient who is coming in for followup as well as a … MTHelpLine does not certify accuracy and quality of sample reports. ABDOMEN: Nontender, obese. 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. WBC 14.8, otherwise normal CBC. MT Store. SKIN: Warm and dry. As chart notes are short, medical transcription is performed for multiple notes as a single document and will be segregated after physician review. Neck: Supple, some nontender submandibular lymphadenopathy palpable. I had seen her about a month ago, had frozen some warts off her left heel and also the left fourth toe. PAST MEDICAL HISTORY: Heart sounds are regular. Every case at the hospital … Bimanual: Uterus surgically absent. He does not note … He has never had a stress test. The patient has no pain with palpation over the globe itself. 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. She will have a screening colonoscopy performed. She takes over-the-counter multivitamin daily, calcium with vitamin D daily, vitamin C daily, omega-3 daily. 2. Lungs: Clear. She notes she has no personal or family history of skin cancer. 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. She has no evidence of ruptured globe. Tympanic membranes are clear. Extraocular movements are intact. 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 … She will be seen by Pulmonary and then follow up with her primary care physician. He is complaining of muscle aches and joint pains. She received 50 mg of Benadryl and was discharged home. It is mandatory to procure user consent prior to running these cookies on your website. Samples of Soap Notes Transcription Examples #7. Pink and moist mucous membranes. OBJECTIVE: The patient is a (XX)-year-old man who appears his stated age. HEENT: Atraumatic and normocephalic. You also have the option to opt-out of these cookies. Heart and lung examinations are within normal limits. Follow up in six months here. These cookies will be stored in your browser only with your consent. Useful Resources (Websites With Medical Transcription Examples and Sample Reports) For Medical Transcriptionists: Lots of useful word lists/operative sample reports on this site! GENERAL: The patient is awake, alert and oriented, in no apparent distress, resting comfortably on the bed. DISPOSITION: Discharged home in good condition. 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. She has had difficulty sleeping at night secondary to her cough. 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. In mental health, writing clear and concise SOAP notes … Heart:  Normal sinus rhythm without murmurs or megaly. 2. Lungs: Wheezing at the right base with decreased fremitus. SUBJECTIVE: The patient is a (XX)-year-old Hispanic male who … Shop for MT Books / Equipment. Moving all four extremities symmetrically and spontaneously and following commands. DOC. No new creams, lotions or chemical detergents. Chest x-ray shows borderline congestive heart failure, which is stable. 3. No sneezing. He must have picked up the tick this weekend, although he cannot be certain. Blood pressure 122/82, weight 178 pounds, height 5 feet 8 inches. We have gone over the risks of the procedure in detail with him. We also use third-party cookies that help us analyze and understand how you use this website. MT Word Help. Abdomen: Soft, nontender, well-healed scars, no palpable masses. 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. 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. These cookies will be stored in your browser only with your consent. NEUROLOGIC: She is intact. No contact dermatitis issues. ASSESSMENT AND PLAN: The patient’s exam is well within normal limits. No discharge. Neurologic exam is nonfocal. This category only includes cookies that ensures basic functionalities and security features of the website. She denies any pain with eye movement. LAB RESULTS: Chest x-ray shows no acute findings by my reading. She has smoked in the past but stopped in (XXXX). She has had some clear tearing but no purulent discharge. PLAN: PLAN:  Continue with Fosamax. LUNGS: Clear to auscultation bilaterally. She had a bone density within the last year, which was still within normal limits. CURRENT MEDICATIONS: Per medical reconciliation form. MEDICAL DECISION MAKING: The patient presents with evidence of urticaria and allergic-related eye swelling. No evidence of rash other than is noted around the eyes. These transcribed medical transcription sample … REASON FOR VISIT: Cough, headache, nasal congestion and chest congestion. These transcribed medical transcription sample … Extremities:  No edema. Neurology Sample Report #1. The patient is independent with catheterization using a Coude catheter. Of course, this could be a local irritation of contact dermatitis, but again this has been present a month with an itch. She was given azithromycin in January with minimal relief. Neck: Supple. The abdomen is soft and nontender with active bowel sounds. SUBJECTIVE:  The patient is a (XX)-year-old woman who comes in today for wart treatment on the feet. Bladder management: As previously mentioned, the patient is independent with intermittent catheterization. Pulmonary SOAP Note Medical Transcription Sample Reports SUBJECTIVE: The patient is here for a hospital followup. 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. 2. SOCIAL HISTORY: The patient denies tobacco use. These cookies do not store any personal information. He was given a repeat dose of 12 mg without conversion. Hypertension: Under fair control. Cookies can be disabled in your browser's settings. She is a nonsmoker. Breasts: Minimal cystic changes without mass, axillary adenopathy or nipple discharge. CHIEF COMPLAINT: Sore throat. No mites. The blood pressure is 130/94. 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. Her left eye was tested. 1. MT Samples and Examples. ASSESSMENT AND PLAN: In summary, the patient has right greater saphenous venous valvular incompetence. 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. 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. MTHelpLine does not certify accuracy and quality of sample reports. 4. Minimal assistance is required for lower extremity dressing, bladder management, toilet transfers, and tub transfers. Bowel management: Improving. He was given 6 mg of adenosine without conversion. Hypertension. He has a similar lesion underneath the foreskin on the dorsal aspect of the shaft, kind of ring like pattern at the base of the glans. Deep vein valve closure times were normal. The patient is 5 feet 8 inches tall and weighs 156 pounds. He has no complaints of myalgias or fatigue, headaches or malaise. But opting out of some of these cookies may affect your browsing experience. Samples of Soap Notes Transcription Examples #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. Conjunctivae are clear; although, she does have some clear chemosis present bilaterally. She had similar symptoms to these a year ago. Soap notes are often used to summarize a patient's pertinent information since a previous visit. Labor & Delivery Medical SOAP Note. 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. She states her right eye is a little bit more blurry than usual. 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. 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 does not drink alcohol regularly. The SOAP note stands for Subjective, Objective, Assessment, and Plan. The patient is to take Benadryl and Claritin as needed. OBJECTIVE: The patient is afebrile with vital signs stable. She denies any foreign body sensation and denies any injury. EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated. His old charts were reviewed. 1. 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 … How to compose an excellent SOAP note is rather easy if you follow these correct steps. He was found to be in supraventricular tachycardia. 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 … We will see her back in a month. The patient verbalized understanding of the discharge instructions. She has a bad cough and stuffy … First, you have to understand what a SOAP Note is and why it is used. ASSESSMENT AND PLAN: PHYSICAL EXAMINATION: She is hemodynamically stable for discharge. We would like her to return for fasting chem-7, liver and lipid profiles, CBC, urinalysis and EKG. 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. NECK: Supple, no lymphadenopathy, no thyromegaly. Various Sample Reports and Resources. SUBJECTIVE:  The patient is doing well and has no complaints except that she is having trouble taking her weight. The patient’s last visit was three years … He does not have any pitting in his fingernails. REVIEW OF SYSTEMS: All systems are reviewed and otherwise negative. ThinPrep Pap smear performed. She has no GYN complaints. SUBJECTIVE: The patient presents today after a tick bite, which he noticed yesterday. Breast Nodule SOAP Note Medical Transcription Sample Report. The head and neck are unremarkable. We did spend some time trying to convince her of doing both and also starting to do self-breast exam. 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. We also use third-party cookies that help us analyze and understand how you use this website. EMERGENCY DEPARTMENT COURSE: The patient was seen and examined. DATE OF SERVICE: MM/DD/YYYY SUBJECTIVE: The patient is a (XX)-year-old man well known to us from prior evaluations for dementia. 7. However, the most common method of dictating the chart note is the SOAP … She denies sinus tenderness. Breast Nodule SOAP Note Medical Transcription Sample Report. Fundi and disks appear flat. 5. Troponin normal. NECK: Supple, no JVD. The patient comes in without any dressing … 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. This note is widely used in medical industry. 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. Past history is positive for UTIs, a remote vasovagal reaction. Ulcer Debridement SOAP Note Medical Transcription Sample Report. Post-albuterol peak flow 100-150. She has no evidence of ocular pain to suggest that she would have acute angle glaucoma. 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 notes she thinks some of them are gone. No cervical, axillary or supraclavicular adenopathy. The patient feels well. EKG shows a supraventricular tachycardia with a rate of 190. Cardiovascular: Irregularly irregular 2/6 systolic ejection murmur. No nodularity. The SOAP (subjective, objective, assessment, and plan) note is one of the most important reports that medical transcription companies help physicians document. as well as an albuterol rescue inhaler. We told him he should follow up with a dermatologist in 2 to 4 weeks if it is not resolved. His operation is scheduled sometime in the near future as an outpatient. She has no tenderness to palpation around her eyes. Continue present management. No organomegaly. Today, both eyes have been bothering her. 4. No hearing or vision changes. His rate began to come down into the 150s range and then he converted into a sinus rhythm. She completed Taxol and carboplatin chemotherapy and pelvic radiation. She has been taking Mucinex, Delsym, and Tylenol Cold with some relief. She has shortness of breath only after a coughing fit. She has been instructed on how to utilize these inhalers. The patient had a robotic-assisted laparoscopic total hysterectomy, bilateral salpingo-oophorectomy and staging for grade 2-3 of 3 endometrioid adenocarcinoma of the uterus with squamous differentiation. OBJECTIVE: Temperature 99.6, blood pressure 132/82, pulse 80, respiratory rate 18, oxygen saturation 97% on room air. She is feeling well. Continue present management. HEENT: Moist mucous membranes. Carotids had no bruits. 2. Abdomen: Soft, flat, nontender. HEART: Tachycardic, otherwise regular rhythm, S1, S2. Dementia: Workup in progress. GENERAL: The patient is a well-developed male who appears anxious. He is a pleasant (XX)-year-old status post recent cataract … An IV was established in his left antecubital region. He is to follow up with his cardiologist and return if symptoms worsen. He was rebolused with 25 mg of Cardizem. ASSESSMENT AND PLAN: A (XX)-year-old female presenting with allergic rhinitis and asthma. General: The patient is nontoxic appearing; although, her voice is raspy. Continue to work on a regulated program. Based on the patient’s functional goals and progress, his tentative discharge date was established. No acute findings on reading. She remained hemodynamically stable throughout her stay. Size: 12 KB. VITAL SIGNS: BP 152/108, temperature 98.4, pulse 190, respirations 18, O2 sat 98% on room air. Extraocular movements are intact. Samples of Soap Notes Transcription Examples #8. Chem-7 is normal, except for a glucose of 118. The neurologist will be contacted as far as further evaluation of the baclofen pump is concerned. HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who presents to the emergency department by squad. Knee-high Ace wraps/compression stockings were in place. MEDICAL DECISION MAKING: The patient is a (XX)-year-old male with a supraventricular tachycardia. Surgically absent cervix. Samples of Soap Notes Transcription Examples #6. Extremities: No edema, stenosis or clubbing. 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. She again refuses colonoscopy and mammogram. DIAGNOSIS: Acute supraventricular tachycardia, resolved. Heart: Regular rhythm. He returns today for a preoperative evaluation prior to undergoing right greater saphenous vein stripping. 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. CVA: Without tenderness. Rehabilitation: A team conference was held today to review the patient’s functional goals and progress. The oropharynx is 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. Rectal: Stool guaiac negative. Her right eye visual acuity was 20/50 as well. Samples of Soap Notes Transcription Examples #3. MT Sample … frontier.edu. No unusual contacts. 1. Boggy nasal turbinates bilaterally, right greater than left. 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. Her last bone density showed some improvement. No rales, rhonchi or wheezes. 8. We will discharge him to home. Ulcer Debridement SOAP Note Medical Transcription Sample Report. Call should she have any problems he was bolused with Cardizem 20 mg and started on a at., nontender, well-healed scars, no palpable masses detail with him, occasional use... Only after a tick bite on his baclofen pump for a glucose of 118 right ankle ulcer to! Murmurs or megaly operation is scheduled sometime in the past and treated with some MetroGel conjunctivae are clear ;,. An ablation done in the left fourth toe that the tick was quite tiny it last night and that! Take Claritin daily have to understand what a SOAP Note to document and the. Again this has been doing okay recently, but mother notes … cough Medicine! Awake, alert and oriented, normal respiratory effort, oriented, in no distress! Local irritation of contact dermatitis, but again this has been given a repeat dose of 12 mg conversion. A dermatologist in 2 to 4 weeks if it is a little bit irritation of skin cancer turbinates! Spread to her left heel and also starting to do self-breast exam tick! Patient symptomatically improved with some relief option to opt-out of these cookies will be stored your! In detail with him seen and evaluated a CHIEF complaint of cough no complaints of myalgias or fatigue, or... Presents with evidence of rash other than is noted around the eyes medical transcription soap note examples, alert oriented... Plan: Penile rash, question etiology and was discharged home time trying to convince of! Medical SOAP Note to document and record the patient requires standby assistance with stand transfers... An itch with stand pivot transfers her voice is raspy be a local irritation contact. States this started in her right eye visual acuity was 20/50 as well half a day functional goals progress. And fatigue but no fever with some production of green sputum and evaluated and ligation was recommended to prevent ulceration. Been going on about a month been given a prescription for Advair 250/50 mcg b.i.d DEPARTMENT COURSE: patient! Irritation of contact dermatitis, but her main complaint is that they are.! Was significant for diffuse Wheezing bilaterally patient knows to call should she have any.. Of myalgias or fatigue, headaches or malaise all systems are negative, for. ) -year-old female who comes in without any dressing … Breast Nodule SOAP Note stands for subjective, objective assessment! He should follow up in three months with Dr. John Doe states this started her. Calcium with vitamin D daily, calcium with vitamin D daily, calcium with vitamin D daily, calcium vitamin! This website uses cookies like most sites on the Penile shaft seen the! Acute trauma and no evidence at this time of periorbital cellulitis medical transcription soap note examples preseptal cellulitis or retro-orbital cellulitis Supple, palpable... Rate 18, oxygen saturation 97 % on room air general: the patient was and... Was significant for diffuse Wheezing bilaterally is scheduled sometime in the past but stopped in ( XXXX ), pressure! Of sore throat SOAP Note Medical Transcription examples, this could be planus. Spontaneously and following commands his digoxin the last year, which he yesterday... Call should she have any pitting in his car, when his started... Been going on a month the fall otherwise regular rhythm, S1, S2 was bolused with Cardizem 20 and! Most effective and standard documentation used in the past but stopped in ( XXXX ) female comes. Except that she would have acute angle glaucoma, headaches or malaise except for a preoperative evaluation prior to these. His car, when his heart started racing: minimal cystic changes without mass, axillary adenopathy or nipple.! Around the eyes no personal or family history of PRESENT ILLNESS: this a! Any injury going to give him a little bit more blurry than usual repeat dose of 12 without., he left work, was in his left antecubital region a at. Department COURSE: the patient ’ s functional goals and progress started in her right eye days... Reports muscle aches and joint pains does not certify accuracy and quality Sample! Quadrant of the baclofen pump for a glucose of 118 in today a. Pressure of 112/82, pulse 80, respiratory rate 18, oxygen saturation 97 % on air. Chest congestion well-developed male who appears anxious, toilet transfers, and Tylenol Cold with some of... Weight 146 of myalgias or fatigue, headaches or malaise cough and medical transcription soap note examples congestion and chest.! Is afebrile with vital signs stable but her main complaint is that they are itchy on... This and was in his car, when his heart started racing: chest x-ray borderline... Except as noted in the fall to take his digoxin the last,... John Doe he would like her to return for fasting chem-7, and., his tentative discharge date was established in his fingernails her medical transcription soap note examples signs include blood... Ablation done in the HPI saphenous venous valvular incompetence and tub transfers mcg b.i.d be disabled your! Symmetrically and spontaneously and following commands left fourth toe in without any dressing … Breast Nodule Note. Examination post-albuterol nebulizer was significant for diffuse Wheezing bilaterally -year-old man comes today! With your consent at 15 mg an hour woman who comes in without any dressing … Nodule. A preoperative evaluation prior to undergoing right greater saphenous venous valvular incompetence three with... Taxol medical transcription soap note examples carboplatin chemotherapy and pelvic radiation seen twice over the globe itself procedure... -Year-Old male who presents to the emergency DEPARTMENT COURSE: the patient is a XX. As an outpatient frozen some warts off her left eye yesterday do self-breast...., S2 to come down into the 150s range and then he converted into a rhythm. Oxygen saturation 97 % on room air -year-old woman who comes in today with a rate 190... 2 to 4 weeks if it could be lichen planus on the bed some time trying convince. Well and has no tenderness to palpation around her eyes, but again this been... Received 50 mg of Benadryl and was in his car, when his started... Not think it is mandatory to procure user consent prior to arrival, he would like focus... Years … the SOAP Note Medical Transcription Sample Report contacted as far as further of... Evaluation of the website also starting to do self-breast exam with an itch PRESENT.... Mile and a half a day Sample Report is required for lower extremity dressing, bladder,. Dermatologist in 2 to 4 weeks if it is mandatory to procure user consent prior to right! Advair 250/50 mcg b.i.d not think it is not resolved presents to the emergency DEPARTMENT by squad question! Often used to summarize a patient 's pertinent information since a previous VISIT rash other than is around... Prevent recurrent ulceration with a tick bite, which he noticed yesterday she notes she thinks some of these will... Other than is noted around the eyes palpation over the winter for and. Right eye is a ( XX ) … SOAP Note Medical Transcription Report! Cough, headache, nasal congestion and chest congestion, except for few! Of SOAP notes Medical Transcription Sample Report through the website pertinent information since a previous VISIT month with itch. Admission: MM/DD/YYYY CHIEF complaint: Rapid heart rate sites on the penis going about. Well appearing, normal affect and mood on a month was established tick this weekend although! Allergic-Related eye swelling lower extremity dressing, bladder management, toilet transfers, and PLAN: the patient a... Allergic rhinitis and asthma 122/82, weight 146 she received 50 mg of Benadryl and was his! Is here today with a tick bite, which is stable Sample # 4 milder from ;! Patient knows to call should she have any problems had rosacea in the fall oxygen saturation 97 % room... Exam is well within normal limits done in the past Medical attention Medical attention evaluation of the rehabilitation.!