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Category: Orthopedic Surgery

Open Treatment of Trimalleolar Ankle Fracture Sample Report

DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE DIAGNOSIS: Right trimalleolar ankle fracture. POSTOPERATIVE DIAGNOSIS: Right trimalleolar ankle fracture. OPERATION PERFORMED: Open treatment of trimalleolar ankle fracture with fixation of the fibula. SURGEON: …

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Pharyngitis SOAP Note Medical Transcription Sample Report
DATE OF SERVICE: MM/DD/YYYY REASON FOR VISIT: Pharyngitis. SUBJECTIVE: The …
Samples of SOAP Notes Medical Transcription Examples
SUBJECTIVE: The patient is a (XX)-year-old man with a history …
Achondroplastic Dwarfism SOAP Note Sample Report
SUBJECTIVE: The patient comes in for a followup appointment. She …

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Physical Exam Template
PHYSICAL EXAM: GENERAL: The patient is an awake and alert, very socially engaging (XX)-month-old male …
Physical Exam Medical Transcription Examples
PHYSICAL EXAM: The patient is an elderly man who appears slightly younger than his stated …
Normal Physical Exam Template Samples
Physical Exam Format 1: Subheadings in ALL CAPS and flush left to the margin. PHYSICAL …

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Rash Medical Consultation Sample Report
REASON FOR CONSULT: Pruritic rash. HISTORY OF PRESENT ILLNESS: The …
Alopecia Areata Chart Note Medical Transcription Sample …
SUBJECTIVE: The patient is a (XX)-year-old seen in consultation because …
Followup Skin Check Dermatology Chart Note Sample
DATE OF SERVICE: MM/DD/YYYY CHIEF COMPLAINT: Followup skin check. HISTORY …

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Rhytidectomy and Blepharoplasty Procedure Sample Report
DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE DIAGNOSIS: Aging face. POSTOPERATIVE DIAGNOSIS: …
Submental Liposuction Cosmetic Transcription Sample Report
DATE OF OPERATION: MM/DD/YYYY PREOPERATIVE DIAGNOSES: 1. Submental lipodystrophy. 2. …
Lacerations Irrigation Debridement Procedure Sample Report
DATE OF PROCEDURE: MM/DD/YYYY PREOPERATIVE DIAGNOSIS: Multiple complex lacerations of …

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Right Retrograde Pyelogram Procedure Sample Report
PREOPERATIVE DIAGNOSIS: Rectal cancer with right ureteral involvement. POSTOPERATIVE DIAGNOSES: …
Transurethral Resection of Prostate Sample Report
PREOPERATIVE DIAGNOSIS: Benign prostatic hypertrophy with obstruction and urinary retention. …
Cystoscopy and Suprapubic Tube Placement Sample
Cystoscopy and Suprapubic Tube Placement Sample Report DATE OF OPERATION: …

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Physical Therapy SOAP Note Examples
SUBJECTIVE: The patient is a (XX)-year-old male. The patient came …
Physical Therapy Progress Note Sample Report
HISTORY: This patient is a (XX)-year-old male with pain to …

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Review of Systems Medical Report Examples
REVIEW OF SYSTEMS: GENERAL: No fevers, sweats, shakes, chills or …
Normal Review of Systems Transcription Samples
REVIEW OF SYSTEMS: Negative for headache, syncope, diplopia, dysarthria, dysphonia, …
Review of Systems Normal Template Samples
REVIEW OF SYSTEMS: CONSTITUTIONAL: The patient denies fever, chills or …

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