Sample Report Formats

SOAP/Progress Note (full page style)

DOCTOR/CLINIC NAME

Address1

Address2, City, Zip

Telephone #: (000) 000-0000

PATIENT NAME: LAST, FIRST

DOB:  00/00/00

DOS:   00/00/00

SUBJECTIVE:

This is a 78-year-old white female with multiple complaints. She has a history of chronic sinusitis, esophagitis, a fibromyalgia-type syndrome, and depression. She complains today of continued problems with pain in the left cheek and preauricular area, especially in the morning. The pain gets very intense at times. She also has a great deal of postnasal drainage which gives her a sour feeling in her stomach. She also complains of some dizzy spells over the last few months, usually when she is working around the house. These are associated with some sweating and nausea. She has not ever had any loss of consciousness. She also complains of recurrent problems with constipation, especially over the last three months. She has been using Correctol. This tends to give her runny stools for a day and then she has constipation again the next day. She has tried taking Colace. This was not helpful.

OBJECTIVE:

General: She is a well-nourished, well-developed, elderly white female in no acute distress. She appears somewhat sad and tearful. HEENT: Tympanic membranes are clear bilaterally. Nose has some pale mucosa, otherwise clear. She has tenderness along the left maxillary and left preauricular areas, and some mild temporomandibular joint tenderness. Throat is clear. Neck is supple. Lungs: Clear to auscultation. Cardiovascular: Regular rate and rhythm without murmur. Abdomen: Soft and diffusely tender to a mild degree. Bowel sounds are active.

ASSESSMENT:

1. Depression.
2. Recurrent sinus pain.
3. Constipation.
4. Esophagitis.

PLAN:

1. She has been off Zoloft for a while, so we will have her resume that. There is no record in the chart of her ever having an adverse reaction to it.
2. Beconase AQ 2 puffs b.i.d.
3. For her constipation, I recommended using Metamucil or some other type of similar fiber, and increasing her fluid intake. She is going to make an appointment with Dr. Suess at his next opening, so that he can follow up on how she is doing with these changes. If she continues to have the sinus pain, we may need to refer her to an otolaryngologist.

____________________________

<Doctor’s Name, M.D.>

<Doctor’s Initial>: <MT Initial>

D: 08/28/XX <Date dictated>

T: 08/29/XX <Date transcribed>

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SOAP/Progress Note (continuous page style)

LAST, FIRST                         07/07/07

S:        Epigastric pain. Improved with diet. Plan previously described.

O:        Abdomen: Benign.

A:        1) Epigastric discomfort improved. 2) Obesity.

P:        Continue 1200 ADA diet. Return for recheck in three months for a

follow-up, sooner p.r.n.

______________________________

Lewis V. Franklin, M.D.

LVF/mjt

LAST, FIRST                         07/07/07

S:        Epigastric pain. Improved with diet. Plan previously described.

O:        Abdomen: Benign.

A:        1) Epigastric discomfort improved. 2) Obesity.

P:        Continue 1200 ADA diet. Return for recheck in three months for a

follow-up, sooner p.r.n.

______________________________

Lewis V. Franklin, M.D.

LVF/mjt

LAST, FIRST                         07/07/07

S:        Epigastric pain. Improved with diet. Plan previously described.

O:        Abdomen: Benign.

A:        1) Epigastric discomfort improved. 2) Obesity.

P:        Continue 1200 ADA diet. Return for recheck in three months for a

follow-up, sooner p.r.n.

______________________________

Lewis V. Franklin, M.D.

LVF/mjt

LAST, FIRST                         07/07/07

S:        Epigastric pain. Improved with diet. Plan previously described.

O:        Abdomen: Benign.

A:        1) Epigastric discomfort improved. 2) Obesity.

P:        Continue 1200 ADA diet. Return for recheck in three months for a

follow-up, sooner p.r.n.

______________________________

Lewis V. Franklin, M.D.

LVF/mjt

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History & Physical  

DOCTOR/CLINIC NAME

Address1

Address2, City, Zip

Telephone #: (000) 000-0000

PATIENT NAME: LAST, FIRST

DOB:  00/00/00

DOS:   00/00/00

HISTORY OF PRESENT ILLNESS: This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month. The patient also reports a 15-pound weight loss. He denies fever, chills and sweats. He denies cough and diarrhea. He has mild anorexia.

REVIEW OF SYSTEMS: As outlined above.

PAST MEDICAL HISTORY: Essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis. He had a recent PPD which was negative in August 1994.

MEDICATIONS:  None.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  He occasionally drinks and is a nonsmoker. The patient participated in homosexual activity in Haiti during 1982 which he described as "very active." Denies intravenous drug use. The patient is currently employed.

FAMILY HISTORY: Unremarkable.

PHYSICAL EXAMINATION:  
GENERAL: This is a thin, black cachectic man speaking in full sentences with oxygen.
VITAL SIGNS:  Blood pressure 96/56, heart rate 120. No change with orthostatics. Temperature 101.6 degrees Fahrenheit. Respirations 30.
HEENT:  Funduscopic examination normal. He has oral thrush.
LYMPH:  He has marked adenopathy including right bilateral epitrochlear and posterior cervical nodes.
NECK:  No goiter, no jugular venous distention.
LUNGS:  Bilateral basilar crackles, and egophony at the right and left middle lung fields.
HEART:  Regular rate and rhythm, no murmur, rub or gallop.
ABDOMEN:  Soft and nontender.
GENITURURINARY:  Normal.
RECTAL:  Unremarkable.
SKIN:  The patient has multiple, subcutaneous mobile nodules on the chest wall that are nontender. He has very pale palms.

LABORATORY AND X-RAY DATA: Sodium 133, potassium 5.3, BUN 29, creatinine 1.8. Hemoglobin 14, white count 7100, platelet count 515. Total protein 10, albumin 3.1, AST 131, ALT 31. Urinalysis shows 1+ protein, trace blood. Total bilirubin 2.4, direct bilirubin 0.1. Arterial blood gases: pH 7.46, pC02 32, p02 46 on room air. Electrocardiogram shows normal sinus rhythm. Chest x-ray shows bilateral alveolar and interstitial infiltrates.

IMPRESSION:
1. Bilateral pneumonia; suspect atypical pneumonia, rule out Pneumocystis carinii pneumonia and tuberculosis.
2. Thrush.
3. Elevated unconjugated bilirubins.
4. Hepatitis.
5. Elevated globulin fraction.
6. Renal insufficiency.
7. Subcutaneous nodules.
8. Risky sexual behavior in 1982 in Haiti.

PLAN:
1. Induced sputum, rule out Pneumocystis carinii pneumonia and tuberculosis.
2. Begin intravenous Bactrim and erythromycin.
3. Begin prednisone.
4. Oxygen.
5. Nystatin swish and swallow.
6. Dermatologic biopsy of lesions.
7. Check HIV and RPR.
8. Administer Pneumovax, tetanus shot and Heptavax if indicated.

____________________________

<Doctor’s Name, M.D.>

<Doctor’s Initial>: <MT Initial>

D: 08/28/XX <Date dictated>

T: 08/29/XX <Date transcribed>

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Consultation Report   

DOCTOR/CLINIC NAME

Address1

Address2, City, Zip

Telephone #: (000) 000-0000

PATIENT NAME:  LAST, FIRST

DATE OF CONSULTATION:  00/00/00

REASON FOR CONSULTATION:  Cardiology.

REFERRING PHYSICIAN:  George Washington, M.D.

CONSULTING PHYSICIAN:  Abraham Lincoln, M.D., F.A.C.C.

HISTORY OF PRESENT ILLNESS:  The patient is an 82-year-old female who was admitted from the nursing home with respiratory failure. The patient has had a recent history of a non-Q wave myocardial infarction with subsequent balloon intervention to the ramus branch with stenting and good results. She also had, at that time, a sick sinus conduction system disease with paroxysmal arrhythmia and tachycardia/bradycardia type symptomatology with ultimately the placement of a permanent pacemaker. It was a sequential type Integrity AFXDR, Model # 5346. The patient did well in the nursing home until the day when she presented to the emergency room with pulmonary edema. She was intubated and was subsequently stabilized.

MEDICATIONS: The patient had been on some amiodarone in the nursing home at 200 mg b.i.d. Also, she was on Demadex 100 mg one-half tablet daily, Amaryl 2 mg daily, Coumadin daily, Humulin 70/30 insulin mixture at 30 units in the a.m. and 25 units p.m., potassium 20 mEq daily, Tegretol 200 mg t.i.d., Altace 2.5 mg daily, calcium carbonate one tablet daily, aspirin 325 mg p.o. daily, isosorbide mononitrate 30 mg daily, Diltiazem XR 240 mg daily, Toprol XL 50 mg daily, and prednisone 10 mg daily. It is unclear as to why she was taken off of her Plavix, but she was to continue on the Plavix in light of her recent stent placement. The patient was treated with Solu-Medrol in the emergency room and was given Lasix 40 mg intravenously and was placed on a low dose of dopamine at 3 mcg/kg per minute and 5 mcg of intravenous nitroglycerin.

PHYSICAL EXAMINATION:
GENERAL: When awake, she is somewhat combative. She is currently sedated on Diprivan.
VITAL SIGNS: Blood pressure 140/60. Recheck seemed to stay in the range of 110-140. The initial rhythm of her heart was 139 which is clearly a pacemaker mediated tachycardia. The pacemaker was subsequently reprogrammed with immediate resolution of that tachycardia.
NECK: Jugular venous pressure appears to be normal.
LUNGS: On the ventilator, the lungs demonstrate to be fairly clear.
HEART: Demonstrates S1 less than S2. No S3 is noted.
ABDOMEN: Obese and fine to examination.
EXTREMITIES: No edema.

LABORATORY DATA: Cardiac enzymes reveal: Mild troponin level bump is noted at 0.20. Myoglobin assay 92.8. CK-MB 4.5 (normal less than 4.1). Total CPK, however, is 42. Hemoglobin and hematocrit are 11 and 34. White blood cell count 13,000. Platelet count 290,000. BUN 33. Creatinine 1.7. Glucose 317. Potassium 4.0. Magnesium 4.7. Phosphorus 4.2.

ASSESSMENT: The cardiac status at this point appears to be more stable with the rhythm potentially improving her pulmonary status. I suspect this whole scenario is related to tachyarrhythmia and that currently, hopefully, with the reprogramming, this will be a thing of the past. Meanwhile, there are severe other medical problems including the chronic obstructive pulmonary disease, the diabetes mellitus, hypertensive heart disease. These will be stabilized.

Thanks so much for allowing us to share in her management. We will follow as needed.

____________________________

<Doctor’s Name, M.D.>

<Doctor’s Initial>: <MT Initial>

D: 08/28/XX <Date dictated>

T: 08/29/XX <Date transcribed>

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General Correspondence (Letter format) 

DOCTOR/CLINIC NAME

Address1

Address2, City, Zip

Telephone #: (000) 000-0000

August 28, 2000

Joseph White, M.D.

Clinic Name .

Address

City, STATE zip

RE:      Last, First

DOB:   01-08-1999

Dear Dr. Joe:

We rechecked (First Last) under anesthesia on November 21. It has been nine

months since he completed his course of external beam radiation therapy as

management of unilateral sporadic retinoblastoma in the left eye.

On our exam today, our findings remain the same as on our prior exam in

August. The tumor is completely regressed, and there is no evidence of viability.

There are no new tumors in the left eye. The optic disc is healthy, and there are

no signs of radiation retinopathy or papillopathy.

The right eye is perfectly normal, with no evidence of retinoblastoma. Regarding

the visual prognosis, because of the macular location of the regressed

retinoblastoma, his visual prognosis is very guarded. We will try patching of the

right eye in an attempt to stimulate any possible vision in the left eye.

Thank you for allowing us to assist in his care.

Very sincerely yours,

____________________________

<Doctor’s Name, M.D.>

<Doctor’s Initial>: <MT Initial>

D: 08/28/XX <Date dictated>

T: 08/29/XX <Date transcribed>

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