Medical transcription soap notes

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CHEMOTHERAPY CLINIC FOLLOWUP NOTE

DATE OF VISIT: XX/XX/XXXX

SUBJECTIVE: The patient returns to clinic today for continued evaluation and treatment of his marginal zone lymphoma. He has completed 3 weeks of maintenance Rituxan. He is tolerating this quite well. He denies any fevers, chills, or night sweats. His only complaint is feeling cold. His wife feels this is new, he states it has been that way since he came back from XX.

OBJECTIVE:

VITAL SIGNS: TEMPERATURE: 97.3 degrees Fahrenheit. BLOOD PRESSURE: 125/60. PULSE: 70. WEIGHT: 209.4 pounds.

Laboratory data from today: CBC - white count 3.3, hemoglobin 13.8, hematocrit 39.2, platelet count 123, and absolute neutrophil count 1900. Chemistries and liver function tests are normal other than a total protein of 6.5 and an LDH of 195.

ASSESSMENT: A XX-year-old gentleman with marginal zone lymphoma. We will complete his maintenance Rituxan today. He will return in 2 months with followup CT scans.

PLAN:

1. Return to oncology special clinic on XX/XX/XXXX.

2. CBC, CMP, LDH, and CT scans of chest, abdomen, and pelvis to be performed that day.

Patient Name

Patient Medical Record Number

Please note:

All identifying information has been omitted from our sample reports to protect privacy of patients involved. 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. 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. Before submitting any work, you should consult your Book of Style, client, or instructor for further direction. No copy of this material in whole or in part is to be made without written permission.

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Medical Transcription Sample Reports

This is a medical transcription sample report in the form of a SOAP note. To read more about medical transcription soap notes please visit Anatomy of a SOAP Note.

Soap Notes

Soap notes are often used to summarize a patient's pertinent information since a previous visit. You will notice that most of the information in this medical transcription sample is brief, succinct, and has very little historical information.

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