SOAP Note Medical Transcription Sample Reports

SUBJECTIVE:  The patient presents in followup regarding her left knee injury. She sustained an isolated closed nondisplaced left tibial plateau fracture this past Thursday. She has been in a hinged knee brace locked in extension. She has been partial weightbearing on the left lower extremity. She has had no pain. Her swelling has decreased. The brace has been fitting her nicely.

OBJECTIVE:  On examination of the left knee, the brace is removed and the skin is examined. There is minimal soft tissue swelling. There are no skin blisters. Sensation is intact to light touch distally in the distribution of the sural, saphenous, superficial, peroneal, deep peroneal, and tibial nerves. She is able to actively dorsiflex and plantarflex the foot and toes against gravity. There is no calf pain, swelling or tenderness. The knee extensor mechanism is intact. She is able to actively flex to about 95 degrees and fully extend the knee against gravity. There are no palpable defects over the extensor mechanism. There is mild tenderness to palpation of the fracture site.

Radiographs of the left knee demonstrate no change.

ASSESSMENT AND PLAN:  Closed minimally displaced left tibial plateau fracture. The diagnosis was reviewed in detail with the patient. At the present time, we believe it is safe to progress to weightbearing as tolerated. We will unlock the brace. Essentially, the fracture is in a nonarticular area of the bone, and it has not displaced since last Thursday, and she has been weightbearing. We instructed her on how to perform active range of motion exercises. She has an appointment to see us in early August for repeat clinical and radiographic evaluation with AP and lateral views of the left knee to be taken with the brace removed. We do not feel that she is safe to return to work at the present time.

————————————————

SUBJECTIVE:  The patient is a (XX)-year-old gentleman who presents with a three-month history of well-defined hyperpigmented lesions on the left lower extremity. He denies pain, itch, and irritation to the areas. He reports frequent sun exposure. The patient states that he currently uses sunscreen. He denies personal and family history of skin cancer. He denies fever, fatigue, and chills, and is otherwise feeling in his usual state of health. He tried topical steroid to the area with minimal relief.

OBJECTIVE:  Limited. Afebrile, temperature 98. Alert and oriented and in no acute distress. Has 0.3 to 0.6 cm hyperpigmented, well marginated, macular lesions present on the anterior and posterior calves, more notable on the left.

ASSESSMENT AND PLAN:  Question of tinea versus other sun exposure and benign skin lesions. We have advised the patient to use over-the-counter Lamisil. In addition, we are requesting dermatology consult, as he is quite concerned about this rash.

SOAP Note Samples

SUBJECTIVE: This (XX)-year-old patient has urethral stricture. He was seen by us previously for a question of prostatitis and urinary tract infection, started on Cipro. He has taken four doses, and he has not improved.

OBJECTIVE: Well gentleman in no obvious discomfort. Temperature 98.2. Very small urethral meatal opening. A specimen was obtained for GC and chlamydia. No drainage seen obviously.

ASSESSMENT: Question of persistent prostatitis.

PLAN: Not getting better in two days is not unusual for acute prostatitis. Because of his unusually small urethral meatus and stricture, we will get Urology consult.

————————————————

SUBJECTIVE:  This (XX)-year-old woman returns. She continues to have about 3 to 4/10 discomfort in the right shoulder. She does not use it often, and she has a very bad two-part fracture with complete displacement, shaft being nearly straight anterior to the humeral head.

OBJECTIVE:  The patient can forward elevate to about 60 degrees, abduct about 60 degrees. She can get her hand to her mouth and her hand to her ear and up to her pocket; although, this is difficult. External rotation is not quite to neutral, internal rotation to the belly. She is otherwise grossly neurovascularly intact distally.

X-rays show continued healing of the fracture with the same amount of displacement, anterior and medial, of the shaft.

ASSESSMENT AND PLAN:  At this point, we talked about options once again, including surgical intervention. She does not want any surgery. She is going to continue to live with her shoulder this way. We will plan to see her back in 2 to 3 months with new x-rays of the right shoulder. Certainly, if things worsen, she will call, and we will see her back sooner.


wordpress visitors