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EAR, NOSE AND THROAT CLINIC FOLLOWUP NOTE
DATE OF VISIT: XX/XX/XXXX
SUBJECTIVE: The daughter brings this patient
in because the right ear had started draining. That ear has a tube in it. The patient was strongly advised to leave the
hearing aid out of that ear.
OBJECTIVE: Under the microscope, the tube is still in position but there is gross pus in the ear
canal. It was cleaned and 5 drops of ofloxacin placed in the ear.
ASSESSMENT: Acute otitis media on the right.
PLAN:
Ofloxacin 5 drops b.i.d. x10 days. I also put in a prescription for Claritin 10 mg per day. The patient was advised to
return in 2 weeks if the ear continued to drain. Otherwise, he will keep the appointment next month.
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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