Custom Search

Word Lists Home

Dermatology Words Male Reproductive Words Musculoskeletal Words Oncology Words Ophthalmology Words Podiatry Words Respiratory Words Urology Words Online College

Listen and Practice Sample Medical Dictation Run-on format Letter formats Samples by specialty History and Physical Family Practice Samples Internal Medicine Samples OB/GYN Samples Well Child Check Samples

Medical Transcription Sample Charts

Below is a sample of what you will find on the sample chart by specialty pages.

SAMPLE

Jane Doe

DOB: 05/11/43

03/14/01

Jane presents today for comprehensive evaluation. The patient's past medical, surgical, social history, and family history should be as per updated front face sheet. The patient's review of systems is remarkable for a history of cold and flu-like illness that has been present for the last two to two and a half weeks. She has had a cough that has been nonproductive. She has had no facial or tooth pain. She has noted no colored nasal drainage. She has had no fevers or chills. She has had some loose bowel movements. She has had one emesis. She states she continues to have cough. Her chest feels sore because of all the coughing. She states her runny nose has diminished somewhat today. Review of systems is otherwise negative.

PHYSICAL EXAMINATION:

VITALS: Height 63-1/2". Weight is 178 pounds, which is down 7 pounds. Pulse 60. Blood pressure

106/72.

SKIN: No suspicious lesions.

HEENT:Pupils are equal and reactive to light. The extraocular movements are intact. Funduscopic exam

shows thediscs to be flat and without hemorrhages or exudates. The pharynx is clear. Tympanic

membranes are normal.

NECK:No adenopathy, thyromegaly, or bruits.

CHEST:Lungs are clear to auscultation and percussion.

CARDIAC:Examination shows normal S1 and S2 without S3, S4, or murmur.

BREASTS:No masses or discharge. No axillary adenopathy is noted.

ABDOMEN:Bowel sounds are active. No hepatosplenomegaly, tenderness, or masses are noted.

Normalexternal genitalia. Uterus and cervix are surgically absent. Bimanual exam shows no masses.

RECTOVAGINAL:Confirmed.

EXTREMITIES:No clubbing, cyanosis, or edema. Pulses are 2+ and full without bruits.

NEUROLOGIC:Nonfocal.

NODES:No lymphadenopathy is noted.

LABS:Laboratory studies are pending and will be called to Lab Talk 604751.

ASSESSMENT:

1.Health maintenance exam.

2.Pelvic exam and Pap smear.

3.Migraine headache without aura.

4.Acute URI.

5.Hyperlipidemia.

PLAN:

Will advise the patient of her laboratory results via Lab Speak. She will follow up here in six months. Will recheck her lipids at that time. Patient will call if she develops any fevers, chills, productive cough or colored sinus drainage.

PENDING LABS: Hemogram, urinalysis, basic, lipids, SGOT, CPK, stool for Hemoccult.

LABS/DIAGNOSTIC ORDERS: Lipids in six months.

NEXT APPOINTMENT: Follow up in six months.

___/ht:slh _____________________, M.D.