Medical transcription soap notes

The Online Resource for Medical Transcription Professionals

CARDIOLOGY FOLLOWUP NOTE

DATE OF VISIT: XX/XX/XXXX

SUBJECTIVE: This patient, who is XX years of age returns for cardiologic followup. The patient has known coronary artery disease and had a coronary artery bypass in XXXX. He underwent cardiac catheterization most recently at XXXX Medical Center in May XXXX and I coincidentally happened to be the attending for that procedure. At that time the patient was seen to have a patent LIMA to the LAD, the LAD being diffusely diseased. The patient had had a patent SVG to OM. The native circumflex system was dominant and supplied a PDA which had diffuse disease and was not bypassed. Left ventricular function was normal.

The patient has undergone treadmill stress testing on XX/XX/XX here in the clinic and he exercised for 6 minutes achieving a heart rate of 117 beats per minute, blood pressure 166 systolic, and had chest pain and 0.5 mm of ST segment change. It was felt that this was his stable status.

The patient has nitroglycerin requiring angina about twice weekly. He is a diabetic, hypertensive, hyperlipidemic, and continues to smoke. He also has chronic renal failure.

OBJECTIVE: On physical examination the blood pressure is 138/74, pulse 75 and regular, and weight 200 pounds. The chest is clear. Heart – PMI is not felt, S1 and S2 normal. There is a grade 2/6 systolic murmur at the left sternal border. There is no edema.

ASSESSMENT: The patient states his angina is stable. Based on his last heart catheterization in XXXX in which diffuse disease was noted with normal left ventricular function, I feel as if it is most appropriate to maximize medical therapy.

PLAN:

1. I will increase metoprolol to 100 mg per day.

2. I will have this patient return in followup to reassess him in 4 months with lipids, Chem-20, hemoglobin A1C and an EKG.

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.

Medical Transcription Quick Links:

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.

Medical transcriptionists type many types of reports in the course of their career.

Sample Medical Dictation

In addition to the sample medical transcription reports we have on our web site, we also have several free dictation samples.

You can hear real doctors dictating real medical reports and test your skills at transcribing them.

Please visit our Sample Dictation page for more information.