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Medical Transcription Examples and Sample Reports

WEBA collection of transcribed medical transcription examples and sample reports for reference by medical transcriptionists and allied health professionals.

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Mental Status Examination Medical Transcription Samples

WEBMENTAL STATUS EXAMINATION: This is a patient who appears to be of stated age, casually and neatly dressed and in no acute distress. The patient engaged the examiner …

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Physical Examination Medical Transcription Examples

WEBPhysical Examination Medical Transcription Examples. GENERAL: The patient is awake and alert. VITAL SIGNS: Temperature in the ER was 100.6 degrees, has been 99.6 …

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Physical Exam Section Words and Phrases For Medical …

WEBPhysical Exam Section Words and Phrases For Medical Transcriptionists. VITAL SIGNS: On examination, the patient had a temperature of 101.5 degrees, pulse of 83 per minute, …

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Axis I, Axis II, Axis III, Axis IV, Axis V Diagnosis

WEBAxis IV: Stressors multiple, severe, related to primary support group. Axis V: Global assessment functioning of 45. ASSESSMENT: Axis I: Opioid withdrawal, opioid …

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ER Reports Medical Transcription Samples

WEBER Reports Medical Transcription Sample Reports. ER Reports Sample Report #1. DATE OF ADMISSION: MM/DD/YYYY CHIEF COMPLAINT: Frequency and urgency and a …

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Psychiatric Discharge Summary Medical Transcription Sample Report

WEBPsychiatric Discharge Summary Sample Report #3. DATE OF ADMISSION: MM/DD/YYYY. DATE OF DISCHARGE: MM/DD/YYYY. DISCHARGE DIAGNOSES: Axis I: Major …

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Normal Physical Examination Template Format For Medical …

WEBPE TEMPLATE FORMAT # 4: PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished male in no apparent distress. He is alert and oriented x3. …

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Total Hip Replacement Operative Transcription Sample Report

WEBESTIMATED BLOOD LOSS: 900 mL. DESCRIPTION OF OPERATION: The patient was treated with an epidural catheter prior to entering the operating room for complicated …

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History and Physical Medical Sample Reports

WEBHistory and Physical Medical Transcription Sample Report #3. DATE OF ADMISSION: MM/DD/YYYY. HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old previously …

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Congestive Heart Failure Medical Transcription Consultation …

WEB1. This is a (XX)-year-old male who has multiple coronary risk factors, including diabetes, hypertension, and age who is presenting with weakness and malaise and has been …

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Normal ROS Template Samples For Reference

WEBROS: Denies chest pain, shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, leg edema, leg pain, leg trauma, dizziness or palpitations. Remainder of review of …

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Vascular Surgery SOAP Note Transcription Sample Reports

WEBVascular Surgery SOAP Note Sample Report #2. SUBJECTIVE: The patient is a (XX)-year-old man referred for an opinion regarding left leg DVT. He has been in good health, but …

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Annual Physical Examination Medical Transcription Example

WEBPHYSICAL EXAMINATION: The patient is an elderly male who appears to be not in any distress. Blood pressure is 142/82, heart rate 94, height is 5 feet 6 inches, 182 pounds, …

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Discharge Summary Medical Transcription Sample Reports

WEBMedical Transcription Discharge Summary Sample Report # 3. DATE OF ADMISSION: MM/DD/YYYY. DATE OF DISCHARGE: MM/DD/YYYY. FINAL DIAGNOSES: 1. Fever, …

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Mental Status Exam Example in Psych Medical Reports

WEBMENTAL STATUS EXAM: The patient today presented alert, oriented to time, day of the week, date, month, year, person and place. Motor activity was within normal limits. She …

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Rehabilitation Discharge Summary Medical Transcription Sample …

WEBDiovan 320 mg daily; Coumadin 10 mg every evening, take last dose MM/DD/YYYY; Estraderm 0.05 mg patch apply every Mondays and Thursdays; iron 325 mg b.i.d. with …

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Annual GYN Exam Medical Transcription Sample Reports

WEBSample #2. HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old G0 postmenopausal female who presents today for a routine GYN exam. The patient was …

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Bipolar Disorder Psychiatric Discharge Summary

WEBBipolar Disorder Psychiatric Discharge Summary Example Report. DATE OF ADMISSION: MM/DD/YYYY DATE OF DISCHARGE: MM/DD/YYYY IDENTIFICATION: The patient is …

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