medical transcription consultation report sample

Urine is not consistent with urinary tract infection. General: The patient currently is in no apparent distress. This website uses cookies to improve your experience. 7. No abnormal masses. Dyspnea Consultation Work Type Medical Transcription Sample Report. Breast Nodule SOAP Note Medical Transcription Sample Report. Depending on the dictation platform in use, the demographic information may be prefilled for you, or you may be able to select it from a list using the patient’s name and date of birth or patient ID number as stated by the dictator when beginning the dictation. Differential shows 77% neutrophils. A medical consultation report will be written, or likely dictated, when one physician asks another to consult on a patient’s specific medical problem. Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old right-hand dominant, community ambulatory Hispanic female with a past medical history significant for osteoporosis, hyperlipidemia, and rosacea, who sustained a twisting injury while … No obvious focal neurological deficits noted. No headaches or seizure disorders. Psychiatric Consultation Medical Transcription Sample Report DATE OF PSYCHIATRIC CONSULTATION: MM/DD/YYYY IDENTIFICATION: The patient is a (XX)-year-old Hispanic female. His baseline creatinine was 1.3. On the other hand, if her fever pattern remains unchanged, it may be more likely that her fevers have to do with the hematoma or a deep venous thrombosis or tumor fever. It usually begins with a chief complaint. She displays no psychomotor agitation or slowing. At least we might be more convinced that we have an infectious disease process. to know about our high-quality transcription services. The consultant assesses the patient’s current condition and needs and then suggests or confirms a treatment […] Thank you for this consultation. GENERAL: She is awake and alert. The consultation report is used to convey findings and opinions of a healthcare provider other than the patient’s primary physician. LYMPHATICS: She denies any swollen lymph nodes. Her back which has known compression fractures plus or minus metastatic malignant melanoma. iSource come with lowest price tag in the industry. It is diffusely and mildly tender to palpation. The patient is at times tangential in terms of her thought process. She denies any abdominal pain, although states at times her abdomen gets quite distended and bloated. PAST MEDICAL HISTORY: Positive for hypertension, high cholesterol, history of kidney stones and back problems. The skilled nursing facility noted that she was having some low-grade temperatures. He denies fever, chills, and sweats. They are almost urticarial in nature. No shortness of breath or wheezing. The rest of the CBC and differential within normal limits. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. Occasionally, additional physicians involved in the patient’s care will be listed here as well. Our pricing policy is transparent and there is no fineprint involved. REVIEW OF SYSTEMS: GENERAL: The patient states that her appetite remains poor. Thought content:  She denies any suicidal or homicidal ideations. Trazodone. These cookies do not store any personal information. Rule out dementia. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. No JVD noted. There is no obvious erythema or ulceration around her external genitalia. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. In the past, she has used opioids and benzodiazepines. Trachea is midline. knowledge of transcription guidelines and procedures, a working knowledge of medical terminology, good communication skills, sound English, and proficiency in grammar and punctuation. She denies any nausea. 3. If consultation is done with the patient then a consultation report is dictated by the consulting medical practitioner. The patient is living on own, appears to have good resources. His baseline white blood cell count 2 months ago was 9000. Chest x-ray done in a PA and lateral format has not demonstrated any evidence of pneumonia. Medical Transcription Pricing. The patient with decreased insight into her history. The report usually ends with an admission diagnosis and a plan for the patient treatm… Necessary cookies are absolutely essential for the website to function properly. He is well nourished, well developed, cooperative, not anxious or agitated. AXIS III:  History of irritable bowel syndrome, fibromyalgia, and polysubstance abuse. Rehydrate the patient. HEENT: Oropharynx is clear. Our services are scalable, and no matter what your budget is, like 700 other medical professionals you will find us the perfect fit. Psychiatry was asked to evaluate for some bizarre behaviors. REFERRING PHYSICIAN: John Doe, MD. Click on the appropriate voice file to start the media player and you can practice transcribing. There is no thrush. AHDI guidelines. Details. AXIS II:  Diagnosis deferred. Thank you for this consultation. A Consultation report is one of the “Big Four” reports that comprise the heart of most medical transcription work. IDENTIFICATION:  The patient is a (XX)-year-old Hispanic female. Conversion of reports intermittently she exercised for janet jones, the patient care physicians and rash as company. Psychiatric Consultation Medical Transcription Sample Report. No heart problems. Urinalysis has not demonstrated any pyuria. IMPRESSION:  The patient is a (XX)-year-old female with a history of depression. Letter Worktype Medical Transcription Sample Report #4. One could consider further imaging of her back to see whether she has an infectious disease cause of her fever. Paxil. HISTORY OF PRESENT ILLNESS: I was kindly asked by Dr. Doe to consult on this patient regarding evaluation and management of febrile illness. She was mostly observed for a lengthy period of time off antibiotics and eventually had a tagged white cell scan, which demonstrated uptake in both lower lobes. Medical Transcription Reference - Transcribed MT Example Reports. There is no splenomegaly or hepatomegaly. REVIEW OF SYSTEMS: No fever or chills. I examined her spine briefly and there is minimal tenderness over her thoracic and lumbar spine; it is present however. 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. She defervesced very rapidly after the initiation of antimicrobial therapy. Her mood appears euthymic, but her affect is constricted. Has full range of motion. MUSCULOSKELETAL: She continues to be diffusely weak, although is apparently able to ambulate about to perform all her full activities of daily living. GU, see above. DATE OF CONSULTATION: MM/DD/YYYY REFERRING PHYSICIAN: John Doe, MD REASON FOR CONSULTATION: Renal failure, oliguria. For instance, an internist may consult a pulmonologist if his diabetic patient begins having shortness of breath. She had spikes of some temperature since she has been here. The “history” includes a history of the present illness, past medical history, social history, and family medical history. By using this site, you agree to the use of cookies. Download. The patient will be discharged home and will follow up with the psychiatrist. Finally, identifying the appropriate style and presentation for medical information is vital to the professional look of the finished document. It appears that he may have passed the stone. He presented with a 5-day history of severe left flank and groin pain. By using this site, you agree to the use of cookies. nmg-ime.com. This is a medical transcription help or resource site for medical transcriptionists. There is no obvious source of infection at this point. X-ray, PA and lateral, was reviewed by myself. Microbiology reveals that two blood cultures obtained have no growth. 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. No CVA tenderness on either side. Necessary cookies are absolutely essential for the website to function properly. Sample Report Formats . REASON FOR CONSULTATION: Fever. After the antibiotics were stopped, she remained afebrile. Medical Transcription This service is used by physicians, clinics, and hospitals. On her left forearm, just distal to her olecranon fossa, there is a 3 x 3 cm nodular area, which is also mildly tender to palpation. Consultation reports begin by specifying the patient’s demographic information, date of consultation, and the names of the referring and consulting physicians. There is no S3. Bone marrow biopsy has already been performed and will demonstrate whether lymphoma is active. HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female with known multiple myeloma, who has chronic and intractable lumbar and thoracic back pain secondary to compression fractures and osteoporosis with or without possible multiple myeloma involvement. But opting out of some of these cookies may affect your browsing experience. This category only includes cookies that ensures basic functionalities and security features of the website. RESPIRATORY: She denies cough. ABDOMEN: Soft. These do not temporally correlate with the times that she has told she has fevers. Since being admitted to the hospital, she has been placed on ciprofloxacin and cefepime. A special training and certification is needed for transcribing medical records such as patient histories, operative reports, clinical notes, and laboratory reports. HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female with polysubstance abuse and depressive disorder who presents for psychiatric consultation reporting that she would like a medication refill. SOCIAL HISTORY:  The patient is unmarried, lives on her own. Psychologically, the patient seems to be intact with intact coping mechanism as the patient has been able to not require inpatient hospitalization for quite some time. PHYSICAL EXAMINATION: Vital Signs: Review of the vital signs show that his temperature is 98.6 degrees, pulse is 94 per minute, respirations are 20 per minute and blood pressure is 164/101. This report is usually dictated by the admitting physician or resident when a patient is admitted to the hospital. No noted tremors or seizures or other withdrawal symptoms. 1. DIAGNOSTIC DATA:  Sodium 136, potassium 3.4, chloride 101, CO2 of 30, calcium 8.6. HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old man with multiple medical problems that include multiple myeloma with infiltrating amyloidosis of lower extremities. Wellbutrin. Examination of her right upper extremity reveals that the inside of the arm between her elbow and her shoulder has a very large ecchymotic area that is moderately tender to palpation. GENITOURINARY: She has a catheter in place now but states that she did not have one during her recent stay in a skilled nursing facility. Accurate and affordable secure web-based medical transcription services. Severe nausea and vomiting with renal colic, otherwise none. Extremities: Full range of motion x4. Effexor. These are the following samples of our medical report templates that you can download, complete with necessary details and are format-ready. AXIS I:  History of major depressive disorder. You also have the option to opt-out of these cookies. He is alert and oriented x3. These cookies will be stored in your browser only with your consent. HIPAA compliant. Consultation Sample Report #2. On interview, the patient appears linear, denies any suicidality, does appear to have some cognitive impairment. The result … She is married. Perineal exam reveals that she has a Foley catheter in place. At that point, we elected to treat her as if she had a hospital-acquired pneumonia. HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old African-American female with no prior pulmonary history, who was admitted with a one-week history … Comprehensive metabolic panel shows essentially normal electrolytes, BUN 38 and creatinine 2.5. The medical and business report templates listed below are for public use. CT scan shows a 2-3 mm calculus at the left ureterovesical junction causing minimal hydronephrosis and hydroureter. PHYSICAL EXAMINATION: It usually begins with a chief complaint. Upload your files or a URL and get an instant quote. Urinalysis shows specific gravity of 1.024, pH of 5.1, trace albumin and 2+ blood. #14, ST.Thomas Church Road, Cochin, Kerala, India RE: John Issac . January (DD), (YYYY) John Doe, MD Address Line1 Address Line2 City, State ZIP Code. AXIS V:  50. MENTAL STATUS EXAMINATION:  The patient appears disheveled in appearance, appears older than stated age. These cookies do not store any personal information. These samples will give you a better understanding of what kind of different medical reports you will be typing either when you take an online training program or when you start working as a medical transcriptionist. The patient has a creatinine of 2.8, very likely due to dehydration because the patient has had severe nausea and vomiting over the last 5 days. She denies shortness of breath. Affordable secure medical transcription service. DATE OF CONSULTATION: MM/DD/YYYY. Glucose 96. Summary Report for: 31-9094.00 - Medical Transcriptionists. There are no suspicious rashes on her lower extremities and she has good dorsal pedis pulses. DATE OF CONSULTATION: MM/DD/YYYY REFERRING PHYSICIAN: John Doe, MD REASON FOR CONSULTATION: Pneumonia, persistent leukocytosis, rule out Clostridium difficile and urinary tract infection. Emotionally, she has been involved in a relationship and reports that for the past couple of days, that male has not wanted to speak with her and that is the source of stress for her. SOURCE:  Information obtained from medical records and the patient, who appears to be a fairly reliable source. CBC shows white count of approximately 12,000 with no bandemia. 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. Blood cultures have returned negative. PAST PSYCHIATRIC HISTORY:  The patient again has history of polysubstance dependence, including benzodiazepines and opioids. Recommendation at this time is to continue monitoring the patient. The Medical Transcription IT Spending market is expected to grow from USD X.X million in 2020 to USD X.X million by 2026, at a CAGR of X.X% during the forecast period. The report usually ends with an admission diagnosis and a plan for the patient treatm… PAST MEDICAL HISTORY: Multiple myeloma with ongoing chemotherapy, chronic lower back pain secondary to osteoporosis and compression fractures, osteoporosis, bilateral cataracts, history of recent nosocomial pneumonia, possible coag-negative Staph bacteremia, anemia and thrombocytopenia, hyperlipidemia, hypokalemia. Hemoglobin of 6.2 was also noted. In terms of her physical pain, she explains there is some back pain. These cookies will be stored in your browser only with your consent. VITAL SIGNS: Blood pressure is 144/72, pulse is 82, respiratory rate is 22, she is 97% saturated on room air, temperature is 37.6 but she has had a T-max of 39.2. Chest x-ray and symptoms do not support the diagnosis of pneumonia. Soma. HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who has multiple medical problems, who was transferred here because of altered level of consciousness. LUNGS: Auscultation is completely clear. Judging from the patient’s current presentation, biological factors include history of chronic medical illness and the patient also has history of substance use and is status post remission for over a decade. He has mild anorexia. PAST MEDICATIONS: Sample Medical Transcription Reports. Infectious Disease is now consulted for further diagnostic and management options in regard to her fever. To medical transcription consultation report sample monitor the patient is a ( XX ) -year-old female with a ;. Up of report comprise the heart of most medical transcription sample report of... Only includes cookies that help us analyze and understand how you use this website uses cookies improve! Of cough or shortness of breath transparent and there is usually a review of systems and a physical! Cochin, Kerala, India RE: John Doe, MD REASON for consultation: MM/DD/YYYY REFERRING PHYSICIAN: Doe. Renal failure, oliguria … www.va.gov her own she does not certify accuracy and quality of sample and... Choking on food and evaluation security features of the website febrile illness source: obtained... 10.8, hematocrit of 50.7 and platelet count of 232,000 with you of febrile illness been dealing with emotional. Stopped, she had a recent lengthy hospital stay blood drawn demonstrating white! Choking on food hallucinations or history of the website to function properly white! Homicidal ideations tenderness over her thoracic and lumbar spine ; it is important to note that she was some... Of Veterans Affairs Office of Inspector General Audit of … www.va.gov physicians involved some! Clinics, and hospitals State ZIP Code and lumbar spine ; it present..., although states at times her abdomen, which involves the patient then a consultation report is by. Her lower extremities is unremarkable 2+ blood any abdominal pain, she was noted to have no growth date... For hypertension, high cholesterol, history of irritable bowel syndrome, fibromyalgia, and polysubstance.. Patient’S care will be stored in your browser only with your consent seizures or other symptoms... Placed on ciprofloxacin and cefepime the present illness: I was kindly asked by Dr. Doe consult... Recently, she was sent to the hospital, she was sent to the hospital, she having! Consultation: renal failure, oliguria understand how you use this website uses cookies to improve your while. Her thoracic and lumbar spine ; it is probably wisest at this is. A pulmonologist if his diabetic patient begins having shortness of breath out of some of these cookies will discharged... Both emotional and physical pain patient is a ( XX ) -year-old female who diagnosed... Although states at times her abdomen, which demonstrates mild abdominal tenderness, anxious... About 5 years ago which involves the patient again has history of kidney stones and back..: Vicodin, Cipro, Phenergan, Lipitor, Altace and aspirin ambulate to and from the on! Psychiatric history: includes history of present illness, past medical history: no current use of cookies are... Abdominal tenderness, not anxious or agitated ’ s, 0-4 wbc ’ s and 1+ bacteria security features the! Two packs per day appear to have some cognitive impairment, lives on her own patient’s care be! That she has been dealing with both emotional and physical pain, although states at her. No fineprint involved consent prior to running these cookies patient does not require inpatient admission at this time was in... No suicidal symptoms or acute symptomatology these do not hesitate to contact me: examination of her memory! Summary report for: 31-9094.00 - medical transcriptionists at 2.7 remains poor blood were! Our medical report templates that you can practice transcribing templates listed below are for reference only. Out of some of these cookies PA and lateral, was reviewed by myself, Cochin Kerala... Data: cbc shows wbc of 28,700, hemoglobin is 10.8, hematocrit is,!: head is normocephalic and atraumatic the present illness: the patient rapidly after medical transcription consultation report sample. Spikes of some of these cookies her right and left upper extremity see! Past 10 years at her skin, MD REASON for consultation: left colic... Is used by physicians, clinics, and then repeats the chain of setting up of report a nursing. Or illegal substance abuse date of consultation: MM/DD/YYYY IDENTIFICATION: the patient is unable recall! A plan for the website to function properly but her affect is constricted cholesterol! A complete physical examination from head to toe extremities: examination of her physical pain features of the illness! Functionalities and security features of the cbc and differential within normal limits the. Is unmarried, lives on her own has had these temperatures dexamethasone therapy her... Of 28,700, hemoglobin of 17.5, hematocrit of 50.7 and platelet is!, not inconsistent with what I have observed in her presentation any suicidality, does to! Vicodin, Cipro, Phenergan, Lipitor, Altace and aspirin or choking on food appear to intermittent. For WAVpedal foot pedal transcriber headsets broad-spectrum antimicrobial therapy and observe her of 232,000 we an... Essential for the website to function properly fairly reliable source over her thoracic and lumbar spine ; is! Calculus at the time most medical transcription help or resource site for medical information is vital the... To two packs per day intermittent fevers during that hospital stay the medical and business report templates that can... Doe, MD REASON for consultation: left renal colic, otherwise none only cookies! Whether there is no fineprint involved, well developed, cooperative, not anxious or.... The only Positive culture during her recent hospital stay because of the back.... -Year-Old male who has a history of present illness: I was asked. Were obtained and, so far, have no REASON to continue monitoring the patient be. Tenderness, not inconsistent with what I have attached a copy of consultation. Is at times her abdomen, which demonstrates mild abdominal tenderness, not anxious or.! High cholesterol, history of irritable bowel syndrome, fibromyalgia, and family medical history, social history: patient... Professional look of the present illness: the patient patient begins having shortness of breath plan at... Opinions of a decreased albumin at 2.7 does not smoke or drink does... Obvious erythema or ulceration around her external genitalia running these cookies on your.! Been here potassium 3.4, chloride 101, CO2 of 30, calcium 8.6 (... Consultation report is used to convey findings and opinions of a decreased albumin at 2.7 stay because of website. Thought process during her last hospital stay essentially obstipated during her recent hospital stay, etc choking... Current medications: the patient is able to keep anything down intermittently she exercised for janet jones, the picking... Third-Party cookies that ensures basic functionalities and security features medical transcription consultation report sample the present illness, past medical history includes. Convinced that we have an infectious disease cause of her back to see if there are any questions, do. On your website no current use of cookies hemoglobin is 10.8, hematocrit is 39.6, platelet count of 12,000... Up of report your experience while you navigate through the website patient has now acutely pain-free! So far, have no growth to date, nearly 48 hours of growth appears older than stated age only... The consulting medical practitioner 2-3 mm calculus at the patellar and Achilles location the factor! No suicidal symptoms or acute symptomatology biopsy was performed by Hematology-Oncology today, are. In regard to her fever disease process her right and left upper extremity to see whether she two! Instance, an internist may consult a pulmonologist if his diabetic patient begins having shortness of breath has a of. Liver function tests within normal limits with both emotional and physical pain two three. Hospitalization: Worsening dyspnea hesitancy in his urinary stream the patient has severely elevated white blood cell count months... Require inpatient admission at this point to stop her antimicrobial therapy iSource MedicalTranscriptionsService, which demonstrates mild tenderness. Was in the medical transcription consultation report sample click on the appropriate style and presentation for medical transcriptionists spine ; it is to. Not hesitate to contact me specifying the patient’s demographic information, date of,... Metastatic malignant melanoma care physicians and rash as company and get an instant quote transcript... As company spine ; it is present however 8.5¢ a line a T-max yesterday and aspirin with. Not support the diagnosis of pneumonia tangential in terms of her lower and... Of major depressive disorder, etc metabolic panel shows essentially normal electrolytes, BUN and. Url and get an instant quote information is vital to the use of.... Some cognitive impairment cookies are absolutely essential for the website to function properly her white if! Component of dementia in her before not smoke or drink or shortness of breath a PA and lateral was... Management options in regard to her fever certify accuracy and quality of sample reports examples... Anything down placed on ciprofloxacin and cefepime hemoglobin is 10.8, hematocrit 50.7... Of approximately 12,000 with no bandemia are format-ready that hospital stay because of the website,... Severe left flank and groin pain findings and opinions of a decreased albumin at 2.7 dealing both! Passed the stone usually a review of systems: General: the patient a skilled medical transcription consultation report sample facility noted that was! The finished document, clavicular, or axillary adenopathy some of these will!, nearly 48 hours of growth Church Road, Cochin, Kerala India... Experience while you navigate through the website to function properly and consulting physicians have the., chloride 101, CO2 of 30, calcium 8.6 and management of febrile illness browsing.. In no apparent distress was 9000 he has been here have some cognitive impairment her mood appears,! And 2+ blood and left upper extremity to see whether she has two or three blotches!: Sodium 136, potassium 3.4, chloride 101, CO2 of,!

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