FREE 3+ Medical Transcription Report Samples in PDF

Have you heard about medical transcriptions? Do you know what is it all about? Medical transcription service aids in making medical reports based from dictated audio recordings or file coming from physicians, health care providers and even nurses. These people have an undeniably stressful job. They are doing everything they can in order to help patients who are in need. One of the most stressful task that a health care provider may have is transcribing their own notes. It is done by taking audio recordings and making it into a written document that is essential for their own records, medical charts of a patient and in insurance claims. In this article, you will be able to know about medical transcriptions and making a report about it.

3+ Medical Transcription Report Samples

1. Medical Transcription Report Sample

2. Medical Transcription Facts Report

3. Formal Medical Transcription Report

4. Professional Medical Transcription Report

What is a Medical Transcription?

A medical transcription renders and edits dictated reports, notes and even procedures in order to create specific files that is needed to represent the treatment history of a patient. This is very essential in health care industries particularly in huge hospitals. A health care practitioner is going to dictate all the performed procedures done to a patient. Medical transcriptionists will transcribe the oral dictation through a speech recognition software. The file that was being transcribed is considered confidential. These texts may be printed and placed in a patient’s record.

The medical transcriptionists can either be an employee of that hospital or someone who is working as a telecommunicating employee for the hospital. They may serve as an independent contractor who works offsite under a contract of a particular hospital, physician group, clinic, or by another medical transcriptionist who is working directly to the doctors onsite or offsite.

Medical Transcription Sample Report

Colorectal Surgery SOAP Note Transcription Sample Report

DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  The patient is here for a long office visit. He was recently discharged from an outside clinic where he had been admitted after he had a bowel obstruction. He had recurrent strictures of ileum from Crohn’s disease.

He is followed by Dr. John Doe. He finally underwent a resection by Dr. Jane Doe, 2-3 feet of terminal ileum, which was reattached to the colon.

He had some diarrhea treated with Imodium tablets 4 times a day. Otherwise, he has had no nausea or vomiting. His appetite is improved. He has follow-up with the Colorectal Surgery in about a week.

PAST MEDICAL HISTORY:  Other histories include labile blood pressure, hyperlipidemia, reflux esophagitis.

OBJECTIVE:  On examination, his vital signs include blood pressure of 122/84, pulse 82, respirations 18, weight is 240. HEENT:  Sclerae anicteric. Neck was supple. Lungs:  Clear. Heart:  Regular rhythm. No gallop or ectopy. Carotids had no bruits. Abdomen:  Soft, distended. He had a healing midline scar going from the entire midline. He had some mild eschars coming off without signs of infection or drainage. Extremities:  No edema, cyanosis or clubbing. Pedal pulses were intact. Neurologically, he was non-focal.

ASSESSMENT AND PLAN:  The patient is recovering from extensive colorectal surgery with the lower terminal ileum. He is having some postoperative diarrhea, which is to be expected at this time. We can check to see if his CBC, liver profile, albumin are recovered.

His list of medications are aspirin 81 mg a day, he takes B12 1000 mcg monthly intramuscularly. He is going to be restarting his Humira after he has healed from his surgery. He is taking loperamide, which is Imodium 2 tablet 4 times a day for diarrhea. Takes a multivitamin daily, Protonix 40 mg daily. He had been on Welchol, but this has been held and he is now on Metamucil 2 tablets once daily.

We will see him back in 2-3 months. He will call sooner if any problems.
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FAQs

All of the medical transcription services are considered as highly-specialized, so they have to be well-trained and knowledgeable about the job. What they work on is for the purpose of speeding up the process and have more accurate medical records at a lower cost while helping the patients at the same time. You may check out more transcription reports on this article.