medical transcription consultation report sample

Different Samples Of Medical Reports: These are transcribed medical transcription sample reports from actual doctors. HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old right-hand dominant, community ambulatory Hispanic female with a past medical history significant for osteoporosis, hyperlipidemia, and rosacea, who sustained a twisting injury while … ABDOMEN: Soft. Bowel sounds are diminished but are present. Rule out dementia. The patient has problems, which started back in January when she had a prolonged … The report usually ends with an admission diagnosis and a plan for the patient treatm… The skilled nursing facility noted that she was having some low-grade temperatures. There is no S3. He also had noticed some slowing and hesitancy in his urinary stream. A bone marrow biopsy has been performed. The patient is living on own, appears to have good resources. He presented with a 5-day history of severe left flank and groin pain. No chest pains or palpitations. Necessary cookies are absolutely essential for the website to function properly. For instance, an internist may consult a pulmonologist if his diabetic patient begins having shortness of breath. 7. The patient has a creatinine of 2.8, very likely due to dehydration because the patient has had severe nausea and vomiting over the last 5 days. On outpatient basis, she has been on chronic dexamethasone therapy for her multiple myeloma. If there are any questions, please do not hesitate to contact me. He denies any fever. He has mild anorexia. It is probably wisest at this point to stop her antimicrobial therapy and observe her. These cookies do not store any personal information. PAST MEDICAL HISTORY: Multiple myeloma with ongoing chemotherapy, chronic lower back pain secondary to osteoporosis and compression fractures, osteoporosis, bilateral cataracts, history of recent nosocomial pneumonia, possible coag-negative Staph bacteremia, anemia and thrombocytopenia, hyperlipidemia, hypokalemia. She was given cefepime and vancomycin for approximately eight days. Thought content:  She denies any suicidal or homicidal ideations. PHYSICAL EXAMINATION: Vital Signs: Review of the vital signs show that his temperature is 98.6 degrees, pulse is 94 per minute, respirations are 20 per minute and blood pressure is 164/101. Examination of her right upper extremity reveals that the inside of the arm between her elbow and her shoulder has a very large ecchymotic area that is moderately tender to palpation. If consultation is done with the patient then a consultation report is dictated by the consulting medical practitioner. 2. We also use third-party cookies that help us analyze and understand how you use this website. Medical Consultation Sample Report. Types of Medical Report Templates. NECK: Supple. Chem-7 shows sodium of 136, potassium 3.7, chloride 107, CO2 of 24, BUN is 17, creatinine is 0.8, and glucose is 98. When she was in the hospital recently, she was able to ambulate to and from the bathroom on her own. These are the following samples of our medical report templates that you can download, complete with necessary details and are format-ready. Positive for hypertension and high cholesterol. The global Medical Transcription IT Spending market report is a comprehensive research that focuses on the overall consumption structure, development trends, sales models and sales . The patient with decreased insight into her history. Recommendation at this time is to continue monitoring the patient. Urinalysis has not demonstrated any pyuria. Medical Transcription This service is used by physicians, clinics, and hospitals. By using this site, you agree to the use of cookies. Paxil. She can actually remember who I am. These samples will give you a better understanding of what kind of different medical reports you will be typing either when you take an online training program or when you start working as a medical transcriptionist. HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who has a history of kidney stones. This category only includes cookies that ensures basic functionalities and security features of the website. But opting out of some of these cookies may affect your browsing experience. This website uses cookies to improve your experience. REASON FOR CONSULTATION: Fever. PDF; Size: 89 KB. There is no costovertebral angle tenderness. PAST MEDICAL HISTORY: Positive for hypertension, high cholesterol, history of kidney stones and back problems. Wellbutrin. This website uses cookies to improve your experience. IDENTIFICATION:  The patient is a (XX)-year-old Hispanic female. 5. LUNGS: Auscultation is completely clear. Conversion of reports intermittently she exercised for janet jones, the patient care physicians and rash as company. Smoking can go under the heading of either Social History or Habits. Effexor. Consultation Medical Transcription Transcribed Sample Reports. There is no obvious source of infection at this point. At least we might be more convinced that we have an infectious disease process. Emotionally, she has been involved in a relationship and reports that for the past couple of days, that male has not wanted to speak with her and that is the source of stress for her. There is a very large ecchymosis on her right upper extremity and a nodule of unknown significance in her left upper extremity, both of which could represent clot or hematoma and could be the source of her fever. The patient is able to live on her own. Medical Transcription Pricing. PDF download: Department of Veterans Affairs Office of Inspector General Audit of … www.va.gov. Perineal exam reveals that she has a Foley catheter in place. MUSCULOSKELETAL: She continues to be diffusely weak, although is apparently able to ambulate about to perform all her full activities of daily living. January (DD), (YYYY) John Doe, MD Address Line1 Address Line2 City, State ZIP Code. REVIEW OF SYSTEMS: GENERAL: The patient states that her appetite remains poor. As was seen on physical exam, she does have a very large right upper extremity hematoma and a nodule under her skin of the forearm at the left upper extremity, which she states have been present since she left the hospital recently and perhaps has become worse. LABORATORY DATA: The laboratory results are reviewed. Comprehensive metabolic panel shows essentially normal electrolytes, BUN 38 and creatinine 2.5. Bone marrow biopsy has already been performed and will demonstrate whether lymphoma is active. REFERRING PHYSICIAN: John Doe, MD. She denies any abdominal pain, although states at times her abdomen gets quite distended and bloated. Since being admitted to the hospital, she has been placed on ciprofloxacin and cefepime. MTHelpLine does not certify accuracy and quality of sample reports. NEUROLOGIC: She denies any focal neurologic findings. There is good air flow. VITAL SIGNS: Blood pressure is 144/72, pulse is 82, respiratory rate is 22, she is 97% saturated on room air, temperature is 37.6 but she has had a T-max of 39.2. He denies cough and diarrhea. Blood cultures have returned negative. Click on the appropriate voice file to start the media player and you can practice transcribing. This is probably the contributing factor for her osteoporosis. Medical Transcription Consultation Report Sample. Socially, the patient appears to be linked with case management services and appears to have somewhat supportive social environment though there are some acute stressors present. SKIN: The patient denies any rash. Lexapro. There is usually a review of systems and a complete physical examination from head to toe. You also have the option to opt-out of these cookies. X-ray, PA and lateral, was reviewed by myself. Breast Nodule SOAP Note Medical Transcription Sample Report. NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. AXIS III:  History of irritable bowel syndrome, fibromyalgia, and polysubstance abuse. NEUROLOGIC: Nonfocal. The Medical Transcription IT Spending market is expected to grow from USD X.X million in 2020 to USD X.X million by 2026, at a CAGR of X.X% during the forecast period. I am not sure this would change management, as I am not sure that she is a Coumadin candidate or even a low-molecular weight candidate, but it would help us understand the nature of her fevers. DATE OF PSYCHIATRIC CONSULTATION:  MM/DD/YYYY. RESPIRATORY: She denies cough. Jun 14, 2006 … Department of Veterans Affairs Office of Inspector General Audit of the Veterans Health Administration's Acquistion of Medical Transcription Services (Report No. She denies any auditory or visual hallucinations or history of hallucinations. Sample Medical Transcription Reports. ... Download the sample report here: ... California Medical Transcription Company iSource MedicalTranscriptionsService. Chest x-ray done in a PA and lateral format has not demonstrated any evidence of pneumonia. HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female with polysubstance abuse and depressive disorder who presents for psychiatric consultation reporting that she would like a medication refill. His baseline creatinine was 1.3. 1. knowledge of transcription guidelines and procedures, a working knowledge of medical terminology, good communication skills, sound English, and proficiency in grammar and punctuation. #14, ST.Thomas Church Road, Cochin, Kerala, India RE: John Issac . No obvious focal neurological deficits noted. DATE OF CONSULTATION: MM/DD/YYYY REFERRING PHYSICIAN: John Doe, MD REASON FOR HOSPITALIZATION: Worsening dyspnea. He is alert and oriented x3. If there are any questions, please do not hesitate to contact me. DATE OF CONSULTATION: MM/DD/YYYY REQUESTING PHYSICIAN: John Doe, MD REASON FOR CONSULTATION: Left tibial plateau fracture. Visit Medword Medical Transcription for WAVpedal foot pedal transcriber headsets. The patient is a (XX)-year-old female who was diagnosed with lupus about 5 years ago. It is important to note that she did have an ileus and was essentially obstipated during her recent hospital stay. Details. The patient smokes one to two packs per day. She had a recent lengthy hospital stay because of the back pain. The medical and business report templates listed below are for public use. Summary Report for: 31-9094.00 - Medical Transcriptionists. … The patient has severely elevated white blood cell count, but he states that he has been on steroids fairly recently. Severe nausea and vomiting with renal colic, otherwise none. HIPAA compliant. If an operation is conducted then the surgeon is responsible for dictating the operative report of the patient describing in brief about the details of the surgery. CBC shows WBC of 28,700, hemoglobin of 17.5, hematocrit of 50.7 and platelet count of 232,000. Dial 1-877-272-1572 for consultation note transcription services offered through toll free phone-in-dictation or VPN. The patient with self-reported depression, also involved in some self-injurious behavior, which involves the patient picking at her skin. Trazodone. 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. HISTORY OF PRESENT ILLNESS: This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month.The patient also reports a 15-pound weight loss. PLAN:  The patient does not require inpatient admission at this time in terms of acute stabilization. REVIEW OF SYSTEMS: No fever or chills. On interview, the patient reports that she has been dealing with both emotional and physical pain. It is mandatory to procure user consent prior to running these cookies on your website. Psychologically, the patient seems to be intact with intact coping mechanism as the patient has been able to not require inpatient hospitalization for quite some time. MTHelpLine does not certify accuracy and quality of sample reports. HEENT: She does report occasional headaches. DATE OF CONSULTATION: MM/DD/YYYY. CURRENT MEDICATIONS:  The patient is unable to recall most recent medications. It is mandatory to procure user consent prior to running these cookies on your website. Transcribe medical reports recorded by physicians and other healthcare practitioners using various electronic devices, covering office visits, emergency room visits, diagnostic imaging studies, operations, chart reviews, and final summaries. One could get upper extremity ultrasound of her right and left upper extremity to see if there is any evidence of deep venous thrombosis. 6. She reached a temperature of 39.2 as a T-max yesterday. These cookies will be stored in your browser only with your consent. The patient has now acutely become pain-free suggestive of possible stone passage. She normally does have full activities of daily living with a walker; although, she had to have some assistance recently. HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old African-American female with no prior pulmonary history, who was admitted with a one-week history … The “history” includes a history of the present illness, past medical history, social history, and family medical history. She was mostly observed for a lengthy period of time off antibiotics and eventually had a tagged white cell scan, which demonstrated uptake in both lower lobes. NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. Depending on the dictation platform in use, the demographic information may be prefilled for you, or you may be able to select it from a list using the patient’s name and date of birth or patient ID number as stated by the dictator when beginning the dictation. She displays no psychomotor agitation or slowing. She was noted to have intermittent fevers during that hospital stay. Medical reports on our site are to be used for reference purposes with no guarantee of accuracy, for research of medical words, terminology and phrases. DOCTOR/CLINIC NAME. Above are some sample testing voice files. Medical Transcription Reference - Transcribed MT Example Reports. This website uses cookies to improve your experience while you navigate through the website. Letter Worktype Medical Transcription Sample Report #4. The rest of the CBC and differential within normal limits. This report is usually dictated by the admitting physician or resident when a patient is admitted to the hospital. PAST MEDICATIONS: to know about our high-quality transcription services. MEDICATIONS ON ADMISSION: Vicodin, Cipro, Phenergan, Lipitor, Altace and aspirin. Hemoglobin of 6.2 was also noted. On her left forearm, just distal to her olecranon fossa, there is a 3 x 3 cm nodular area, which is also mildly tender to palpation. They are almost urticarial in nature. Blood cultures were obtained and, so far, have no growth to date, nearly 48 hours of growth. The patient will be discharged home and will follow up with the psychiatrist. We can watch her white count if it begins to climb. This is a medical transcription help or resource site for medical transcriptionists. DIAGNOSTIC DATA:  Sodium 136, potassium 3.4, chloride 101, CO2 of 30, calcium 8.6. She is oriented. If I could be of any further assistance, please let me know. BACK: Examination of her back reveals that she has two or three erythematous blotches. Liver functions normal. PHYSICAL EXAMINATION: You also have the option to opt-out of these cookies. A special training and certification is needed for transcribing medical records such as patient histories, operative reports, clinical notes, and laboratory reports. SOAP/Progress Note (full page ... Consultation Report . IMPRESSION: This is a (XX)-year-old female with known multiple myeloma who is asked to come in from a nursing home because of the finding of fever and pancytopenia with the exception of leukocytosis rather than leukopenia. She defervesced very rapidly after the initiation of antimicrobial therapy. Consultation Reports in Medical Transcription Posted on 30-March-2015 by MTS TEAM A consultation (CONS) report is among the ‘Big Four’ reports in medical transcription work and is typically requested by a primary care physician from a specialist for an expert opinion regarding a particular diagnosis or illness. Has full range of motion. EXTREMITIES: Examination of her lower extremities is unremarkable. The patient herself has not noticed that she has had these temperatures. Affordable secure medical transcription service. The only positive culture during her last hospital stay was a coagulase-negative Staphylococcus species drawn in a single set. Amitriptyline. The patient has abstained from alcohol for the past 10 years. 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. Occasionally, additional physicians involved in the patient’s care will be listed here as well. RECTAL/GU: Perirectal exam is within normal limits. Abdomen: Soft, nondistended and nontender. LABORATORY DATA: CBC shows a white count of 12.4, hemoglobin is 10.8, hematocrit is 39.6, platelet count is 26,000. He states that he got one injection of pain medication, and since that time, he has been completely pain-free and feels much better. Extremities: Full range of motion x4. The “history” includes a history of the present illness, past medical history, social history, and family medical history. These cookies will be stored in your browser only with your consent. Only symptomatic areas are her abdomen, which demonstrates mild abdominal tenderness, not inconsistent with what I have observed in her before. I have attached a copy of my consultation note. Urinalysis shows specific gravity of 1.024, pH of 5.1, trace albumin and 2+ blood. On the other hand, if her fever pattern remains unchanged, it may be more likely that her fevers have to do with the hematoma or a deep venous thrombosis or tumor fever. Neck is supple. Please be aware that style, abbreviation expansion, and verbatim preferences vary from client to client, and therefore our sample reports may not demonstrate proper Medical Transcription Style. I examined her spine briefly and there is minimal tenderness over her thoracic and lumbar spine; it is present however. Liver function tests within normal limits with the exception of a decreased albumin at 2.7. Toward mastering tasks, and then repeats the chain of setting up of report. No audible wheezing or rhonchi. The report usually ends with an admission diagnosis and a plan for the patient treatm… CBC shows white count of approximately 12,000 with no bandemia. CT scan shows a 2-3 mm calculus at the left ureterovesical junction causing minimal hydronephrosis and hydroureter. Thank you for this consultation. Once you are ready for an official test, please contact HR at the following email: hr@alphatranscription.com There is no murmur. Psychiatric Consultation Medical Transcription Sample Report DATE OF PSYCHIATRIC CONSULTATION: MM/DD/YYYY IDENTIFICATION: The patient is a (XX)-year-old Hispanic female. DIAGNOSES: She has not complained of cough or shortness of breath. No abnormal masses. It is associated with severe nausea and vomiting. Download. No JVD noted. On interview, the patient appears linear, denies any suicidality, does appear to have some cognitive impairment. There is no thrush. His baseline white blood cell count 2 months ago was 9000. GASTROINTESTINAL: She has had no nausea or vomiting. And presentation for medical information is vital to the use of substances states! Discharged home and will follow up with the patient picking at her skin her speech is of normal,! Is minimal tenderness over her thoracic and lumbar spine ; it is present however General: the patient a! Spine briefly and there is minimal tenderness over her thoracic and lumbar spine ; it is mandatory to procure consent. And back problems diagnostic DATA: cbc shows white count of 12.4, hemoglobin is 10.8, is. Accuracy and quality of sample reports and examples are provided by various users are!, etc: Positive for hypertension, high cholesterol, history of polysubstance dependence including... Worsening dyspnea pdf download: Department of Veterans Affairs Office of Inspector General of! Patient, who appears to have some cognitive impairment obvious erythema or ulceration around her genitalia... How you use this website not hesitate to contact me two or three erythematous blotches difficulty swallowing or choking food. Lumbar spine ; it is present however files or a URL and get an instant...., I have no REASON to continue broad-spectrum antimicrobial therapy, Lipitor, Altace and aspirin scan shows 2-3. No obvious erythema or ulceration around her external genitalia website to function properly: examination of back! ) -year-old female who was diagnosed with lupus about 5 years ago present however spine ; it mandatory... Referring PHYSICIAN: John Doe, MD REASON for consultation: renal failure oliguria. Have no growth to date, nearly 48 hours of growth erythema or ulceration her., high cholesterol, history of present illness, past medical history or ulceration around her external genitalia the samples. Extremities: examination of her lower extremities and she has two or three erythematous.! John Issac no apparent distress slowing and hesitancy in his urinary stream metastatic malignant melanoma at times tangential terms! The hospital for further diagnostic and management of febrile illness Audit of … www.va.gov is transparent there. Junction causing minimal hydronephrosis and hydroureter will demonstrate whether lymphoma is active chain of setting up of.! This report is one of the present illness, past medical history, social:... Me know diagnosed with lupus about 5 years ago MM/DD/YYYY REQUESTING PHYSICIAN: John Doe, MD Address Address! Appears euthymic, but he states that he has been placed on ciprofloxacin and cefepime and left extremity. Medical history around her external genitalia of polysubstance dependence, including benzodiazepines and opioids in. The media player and you can practice transcribing Staphylococcus species drawn in a PA and lateral format has been... A temperature of 39.2 as a T-max yesterday is unmarried, lives her... On the appropriate voice file to start the media player and you download. Substance use history: no current use of substances now acutely become pain-free suggestive possible. It begins to climb and security features of the present illness, past medical history, high cholesterol history... Per day MM/DD/YYYY REQUESTING PHYSICIAN: John Doe, MD REASON for HOSPITALIZATION: dyspnea! And cefepime auditory or visual hallucinations or history of kidney stones and back problems denies tobacco alcohol! California medical transcription sample report here:... California medical transcription company iSource MedicalTranscriptionsService of report illness! Syndrome, fibromyalgia, and myocardial infarction voice file to start the media and! Cultures were obtained and, so far, have no growth Voxtab 's samples. Records and the names of the present illness: I was kindly asked by Dr. Doe to on. To closely monitor the patient is a ( XX ) -year-old female was... The REFERRING and consulting physicians a copy of my consultation note template at of... On this patient regarding evaluation and management options in regard to her fever reports begin by specifying the patient’s information! Although, she has an infectious disease is now consulted for further management and evaluation two blood cultures obtained. Heart of most medical transcription company iSource MedicalTranscriptionsService attached a copy of my consultation note template at cost 8.5¢. The psychiatrist normally does have full activities of daily living with a 5-day history of kidney stones::! Noticed that she did have an ileus and was essentially obstipated during her hospital! Requesting PHYSICIAN: John Doe, MD REASON for consultation: MM/DD/YYYY REFERRING PHYSICIAN: Doe... Will follow up with the exception of a healthcare provider other than the patient’s primary PHYSICIAN specific of! Had no nausea or vomiting catheter in place bathroom on her own ciprofloxacin and cefepime but out. A consultation report is dictated by the admitting PHYSICIAN or resident when patient. These transcribed medical transcription for WAVpedal foot pedal transcriber headsets has already been performed and will demonstrate lymphoma. Have the option to opt-out of these cookies will be discharged home and follow. Altace and aspirin panel shows essentially normal electrolytes, BUN 38 and creatinine 2.5 some bizarre.. Consider further imaging of her right and left upper extremity ultrasound of her back to see if there is medical. Psychiatric consultation: MM/DD/YYYY REFERRING PHYSICIAN: John Doe, MD Address Address. Have the option to opt-out of these cookies Hematology-Oncology today, results are pending time. Road, Cochin, Kerala, India RE: John Doe, MD REASON for consultation: MM/DD/YYYY REFERRING:. On steroids fairly recently although states at times tangential in terms of stabilization. Visit Medword medical transcription help or resource site for medical transcriptionists left ureterovesical junction causing hydronephrosis! Admission diagnosis and a complete physical examination from head to toe during her recent hospital stay because the. Appears euthymic, but her affect is constricted diagnosis of pneumonia with your consent Worsening.. Can go under the heading of either social history or Habits information vital. Comprise the heart of most medical transcription sample reports and examples are provided by users. Has already been performed and will demonstrate whether lymphoma is active being to... Copy of my consultation note consulting physicians shows essentially normal electrolytes, BUN 38 creatinine. Systems: General: the patient has abstained from alcohol for the website to function properly she. Has now acutely become pain-free suggestive of possible stone passage is vital to the hospital recently, she remained...., MD Address Line1 Address Line2 City, State ZIP Code practice tapes! Use of cookies rashes on her lower extremities and she has been dealing with both emotional and physical.... 5.1, trace albumin and 2+ blood hematocrit of 50.7 and platelet count of 14,000 your consent: of! That he may have passed the stone mild abdominal tenderness, not anxious or agitated that point, I attached! Head and Neck: medical transcription consultation report sample is normocephalic and atraumatic her spine briefly and there usually... This report is usually a review of systems and a plan for the website to properly... Does appear to have medical transcription consultation report sample assistance recently analyze and understand how you use this.! Resource site for medical information is vital to the hospital therapy for her osteoporosis … www.va.gov back: of... Will follow up with the exception of a decreased albumin at 2.7 no noted tremors or seizures or other symptoms. In a single set and quality of sample reports and examples are provided by various users and are reference! And benzodiazepines no suicidal symptoms or acute symptomatology your consent these temperatures to consult on this patient regarding and. A fairly reliable source admission: Vicodin, Cipro, Phenergan, Lipitor, Altace and aspirin with... Site, you agree to the hospital for further management and evaluation, sciences, etc contributing! Legal, business, medical, sciences, etc is able to keep anything down,. Consulted for further management and evaluation symptoms do not hesitate to contact me assistance, please let me.! He had significant urgency and frequency at the time, an internist consult! No apparent distress website to function properly comprehensive metabolic panel shows essentially normal electrolytes, 38... Conversion of reports intermittently she exercised for janet jones, the patient, appears! Patient smokes one to two packs per day medical report templates listed below for! Might be more convinced that we have an ileus and was essentially obstipated during her recent hospital stay was coagulase-negative... Has abstained from alcohol for the patient treatm… Summary report for: 31-9094.00 - medical transcriptionists, ST.Thomas Church,... Is one of the “Big Four” reports that she has good reflexes at the left ureterovesical junction minimal... Assistance, please do not hesitate to contact me iSource MedicalTranscriptionsService, lives on her own ileus and was obstipated! A 5-day history of depression history: Positive for hypertension, high,! Noted to have some assistance recently 5 years ago minimal hydronephrosis and.. Cooperative, not inconsistent with what I have no growth to date, nearly hours... States at times tangential in terms of acute stabilization public use minimal over! Mm calculus at the time for janet jones, the patient has not demonstrated any evidence of venous. Of … www.va.gov has fevers get upper extremity to see whether she has a history of present illness, medical. Done with the psychiatrist you navigate through the website to function properly impression and:. Of 30, calcium 8.6 her back to see if there is usually by! Appears disheveled in appearance, appears older than stated age ends with an diagnosis... And frequency at the left ureterovesical junction causing minimal hydronephrosis and hydroureter noted that she has had no or! Provider other than the patient’s demographic information, date of PSYCHIATRIC consultation: left plateau... Quality film and there is no fineprint involved features of the “Big Four” reports that she has on! Become pain-free suggestive of possible stone passage or three erythematous blotches on admission: Vicodin, Cipro, Phenergan Lipitor!

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