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Axis I, Axis II, Axis III, Axis IV, Axis V Diagnosis

WebAxis IV: Stressors multiple, severe, related to primary support group. Axis V: Global assessment functioning of 45. ASSESSMENT: Axis I: Opioid withdrawal, opioid …

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Psychiatric Discharge Summary Medical Transcription Sample Report

WebPsychiatric Discharge Summary Sample Report #3. DATE OF ADMISSION: MM/DD/YYYY. DATE OF DISCHARGE: MM/DD/YYYY. DISCHARGE DIAGNOSES: Axis I: Major …

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Mental Status Examination Medical Transcription Samples

WebMENTAL STATUS EXAMINATION: This is a patient who appears to be of stated age, casually and neatly dressed and in no acute distress. The patient engaged the examiner …

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Physical Examination Medical Transcription Examples

WebPhysical Examination Medical Transcription Examples. GENERAL: The patient is awake and alert. VITAL SIGNS: Temperature in the ER was 100.6 degrees, has been 99.6 degrees …

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Review of Systems Medical Transcription Template Examples

WebReview of Systems Medical Transcription Template Examples. GENERAL: The patient complains of fatigue. No headaches or dizzy spells. HEENT: The patient does have …

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Physical Exam Section Words and Phrases For Medical …

WebPhysical Exam Section Words and Phrases For Medical Transcriptionists. VITAL SIGNS: On examination, the patient had a temperature of 101.5 degrees, pulse of 83 per minute, …

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Congestive Heart Failure Medical Transcription Consultation …

Web1. This is a (XX)-year-old male who has multiple coronary risk factors, including diabetes, hypertension, and age who is presenting with weakness and malaise and has been …

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Normal Physical Examination Template Format For Medical …

WebPE TEMPLATE FORMAT # 4: PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished male in no apparent distress. He is alert and oriented x3. …

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History and Physical Medical Sample Reports

WebHistory and Physical Medical Transcription Sample Report #3. DATE OF ADMISSION: MM/DD/YYYY. HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old previously …

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Physical Exam Normal Medical Template Transcription Samples

WebPhysical Exam Normal Medical Template Transcription Samples. GENERAL: This is a pleasant, cooperative, elderly Hispanic female, who is alert, oriented, and in mild distress …

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Vascular Surgery SOAP Note Transcription Sample Reports

WebVascular Surgery SOAP Note Sample Report #2. SUBJECTIVE: The patient is a (XX)-year-old man referred for an opinion regarding left leg DVT. He has been in good health, but …

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Normal ROS Template Samples For Reference

WebROS: Denies chest pain, shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, leg edema, leg pain, leg trauma, dizziness or palpitations. Remainder of review of systems …

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Annual GYN Exam Medical Transcription Sample Reports

WebSample #2. HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old G0 postmenopausal female who presents today for a routine GYN exam. The patient was …

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Upper Respiratory Tract Infection SOAP Note Sample Report

WebSUBJECTIVE: This is a (XX)-year-old male known to have hypertension, renal failure, diabetes mellitus and has been a chronic smoker. The patient comes in again with …

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Mental Status Exam Example in Psych Medical Reports

WebMENTAL STATUS EXAM: The patient today presented alert, oriented to time, day of the week, date, month, year, person and place. Motor activity was within normal limits. She …

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ER Reports Medical Transcription Samples

WebER Reports Medical Transcription Sample Reports. ER Reports Sample Report #1. DATE OF ADMISSION: MM/DD/YYYY CHIEF COMPLAINT: Frequency and urgency and a …

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Annual Physical Examination Medical Transcription Example

WebPHYSICAL EXAMINATION: The patient is an elderly male who appears to be not in any distress. Blood pressure is 142/82, heart rate 94, height is 5 feet 6 inches, 182 pounds, …

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Bariatric Surgery Medical Consultation Sample Report

Web4. Return for progress check with nurse practitioner at 1 month’s and 3 months’ time and with the nutritionist at 2 months’ and 4 months’ time to comply with national regulations …

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Dyslipidemia SOAP Note Medical Transcription Sample Report

WebMedications include Coreg 25 mg twice daily, clonidine 0.2 mg twice daily, furosemide 20 mg daily, lisinopril 40 mg daily, Lovastatin 40 nightly, Os-Cal 500/200 mg twice daily, …

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