SUBJECTIVE: The patient is a (XX)-year-old man with a history of chronic venous insufficiency and a prior venous ulcer. He returns today for a preoperative evaluation prior to undergoing right greater saphenous vein stripping. He had a right ankle ulcer due to chronic venous hypertension that began in the fall.
After a period of treatment with conservative management using compression therapy, the ulcer ultimately healed. 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. Deep vein valve closure times were normal.
Right greater saphenous vein stripping and ligation was recommended to prevent recurrent ulceration.
OBJECTIVE: The patient is a (XX)-year-old man who appears his stated age. He is awake and alert. The blood pressure is 130/94. Pulse is 86 and regular. Lungs: Clear. Heart sounds are regular. 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.
ASSESSMENT AND PLAN: In summary, the patient has right greater saphenous venous valvular incompetence. We have recommended a right greater saphenous vein stripping and ligation to lower his risk of recurrent venous ulceration.
We have gone over the risks of the procedure in detail with him. He has signed a consent form today. His operation is scheduled sometime in the near future as an outpatient. We have asked him to avoid taking aspirin or anti-inflammatory medications within one week of the operation.
Samples of Soap Notes Transcription Examples #2
SUBJECTIVE: The patient is a (XX)-year-old female. She is a nonsmoker. She has smoked in the past but stopped in (XXXX). She does not drink alcohol regularly. Past history is positive for UTIs, a remote vasovagal reaction. She has had costochondritis, right hip fasciitis, and mild osteoarthritis of the hips and knees. She takes over-the-counter multivitamin daily, calcium with vitamin D daily, vitamin C daily, omega-3 daily.
OBJECTIVE: Her vital signs include a blood pressure of 112/82, pulse 62. She is 5 feet 8 inches, weight 146. BMI is 22.6. HEENT: Pupils are reactive to light. Fundi and disks appear flat. Thyroid: Negative. Pharynx is clear. Neck: Supple. Lungs: Clear to auscultation and percussion. CVA: Without tenderness. Heart: Regular rhythm. No gallop, rub or murmur. Carotids had no bruits. Breasts: Minimal cystic changes without mass, axillary adenopathy or nipple discharge. Abdomen: Soft, flat, nontender. No organomegaly. She has healed scars from removal of benign moles from the right abdominal wall. Extremities: No edema, stenosis or clubbing. Pedal pulses are intact. Neurologic exam is nonfocal. Rectal: Stool guaiac negative. No rectal masses are noted.
ASSESSMENT AND PLAN: The patient’s exam is well within normal limits. We would like her to return for fasting chem-7, liver and lipid profiles, CBC, urinalysis and EKG. She will have a screening colonoscopy performed. She had a bone density within the last year, which was still within normal limits. She will return in six months. Call sooner if any problems.
Samples of Soap Notes Transcription Examples #3
SUBJECTIVE: The patient presents today after a tick bite, which he noticed yesterday. He must have picked up the tick this weekend, although he cannot be certain.
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.
ASSESSMENT AND PLAN: Tick bite. The patient feels well. He has no complaints of myalgias or fatigue, headaches or malaise. 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. 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.
Samples of Soap Notes Transcription Examples #4
SUBJECTIVE: The patient is a (XX)-year-old female who comes in today with a chief complaint of cough. She was seen twice over the winter for cough and nasal congestion. She was given azithromycin in January with minimal relief. She states that five days ago she developed a tickle in the back of her throat. This persisted and evolved into low-grade fever at 99 degrees, cough with occasional green sputum.
She has shortness of breath only after a coughing fit. She has had difficulty sleeping at night secondary to her cough. She denies sinus tenderness. She has rhinorrhea but no nasal congestion. No hearing or vision changes. She has been taking Mucinex, Delsym, and Tylenol Cold with some relief. She reports muscle aches and fatigue but no fever.
OBJECTIVE: Temperature 99.6, blood pressure 132/82, pulse 80, respiratory rate 18, oxygen saturation 97% on room air. General: The patient is nontoxic appearing; although, her voice is raspy. HEENT: Watery eyes. Pupils are equal, round and reactive to light. Extraocular movements are intact. No sinus tenderness. Oropharynx is clear. Boggy nasal turbinates bilaterally, right greater than left. Tympanic membranes are clear. Neck: Supple, some nontender submandibular lymphadenopathy palpable. Cardiovascular: Irregularly irregular 2/6 systolic ejection murmur. Lungs: Wheezing at the right base with decreased fremitus.
Chest x-ray shows borderline congestive heart failure, which is stable. Status post AVR. Pacemaker in place.
Pre-albuterol peak flow was documented at 125-150. Post-albuterol peak flow 100-150. Lung examination post-albuterol nebulizer was significant for diffuse wheezing bilaterally. The patient symptomatically improved with some production of green sputum.
ASSESSMENT AND PLAN: A (XX)-year-old female presenting with allergic rhinitis and asthma.
1. Allergies: The patient has been instructed to take Claritin daily.
2. Asthma: The patient has been given a prescription for Advair 250/50 mcg b.i.d. as well as an albuterol rescue inhaler. She has been instructed on how to utilize these inhalers. She will be seen by Pulmonary and then follow up with her primary care physician.
Samples of Soap Notes Transcription Examples #5
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.
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.
She completed Taxol and carboplatin chemotherapy and pelvic radiation. She has no GYN complaints. Bowel and bladder are without problem.
OBJECTIVE: Alert female in no acute distress. Vital Signs: Stable. Blood pressure 122/82, weight 178 pounds, height 5 feet 8 inches. 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. No cervical, axillary or supraclavicular adenopathy. Abdomen: Soft, nontender, well-healed scars, no palpable masses. Gynecologic: Normal external genitalia. Normal vagina. Surgically absent cervix. ThinPrep Pap smear performed. Bimanual: Uterus surgically absent. No nodularity. Adnexa negative without adenopathy or nodularity or fixation. Rectovaginal is negative.
ASSESSMENT: Normal gynecologic exam, status post IIIA adenocarcinoma.
PLAN:
1. Follow up in three months with Dr. John Doe.
2. Follow up in six months here.
3. The patient knows to call should she have any problems.
Samples of Soap Notes Transcription Examples #6
SUBJECTIVE: The patient is a (XX)-year-old woman who comes in today for wart treatment on the feet. I had seen her about a month ago, had frozen some warts off her left heel and also the left fourth toe. She notes she thinks some of them are gone.
OBJECTIVE: Well appearing, normal respiratory effort, oriented, normal affect and mood. Exam included the hands and feet.
ASSESSMENT AND PLAN: Plantar wart. 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. We will see her back in a month.
Samples of Soap Notes Transcription Examples #7
SUBJECTIVE: A (XX)-year-old man comes in for rash on the penis going on a month. No discharge. No fever. No pain. No unusual contacts. No new creams, lotions or chemical detergents. No contact dermatitis issues. It has been going on about a month, little bit irritation.
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. No weeping or oozing or discharge. 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. No adenopathy. No mites. No excoriations. No lymphadenopathy.
ASSESSMENT AND PLAN: Penile rash, question etiology. This looks to me like a psoriatic plaque. He does not have any pitting in his fingernails. No lesions on his elbows or his knees. He said he has had rosacea in the past and treated with some MetroGel. I also wondered if it could be lichen planus on the penile shaft. We do not have any other good idea. Of course, this could be a local irritation of contact dermatitis, but again this has been present a month with an itch. We are going to give him a little Lotrisone cream. We told him we do not think it is anything worrisome. We told him he should follow up with a dermatologist in 2 to 4 weeks if it is not resolved.
Samples of Soap Notes Transcription Examples #8
SUBJECTIVE: The patient is doing well and has no complaints except that she is having trouble taking her weight. Her last bone density showed some improvement. She does walk about a mile and a half a day. She is feeling well. She again refuses colonoscopy and mammogram. We did spend some time trying to convince her of doing both and also starting to do self-breast exam.
OBJECTIVE: Blood pressure 142/80, pulse 60 and regular, weight 154, which is stable. Chest: Clear to P and A. No rales, rhonchi or wheezes. Heart: Normal sinus rhythm without murmurs or megaly. Extremities: No edema.
ASSESSMENT: Osteopenia.
PLAN: Continue with Fosamax. Return in 6 months.
