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CHEMOTHERAPY CLINIC FOLLOWUP NOTE
DATE OF VISIT: XX/XX/XXXX
SUBJECTIVE: The patient returns to clinic today for evaluation. His last phlebotomy for his secondary erythrocytosis was 1 year ago. He states he is feeling fine. He denies any headaches,
no changes in thinking or other problems. No fevers, chills or night sweats.
OBJECTIVE: Well-appearing man with ruddy
facies.
Laboratory data from today: Chemistries are notable for a glucose of 133, total protein 8.2, otherwise normal. CBC: White count 7.4, hemoglobin 19.1, hematocrit 56.2, platelet count 211. Differential: 68.2 neutrophils and 22.2
lymphocytes.
ASSESSMENT: Patient is a XX-year-old gentleman with secondary polycythemia who is doing quite well. Today his hematocrit is above 55%. Will proceed with phlebotomy.
PLAN:
1. Phlebotomy 500 cc today.
2. Return
to clinic in four months with CBC, CMP and schedule phlebotomy.
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
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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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