Medical Transcription Sample

I thought I would show you what a typical examination that I type regularly is like. This will show you the importance of taking a medical transcription course. As someone who had no prior medical experience, I could not type this dictation without having first taken my medical transcription course.

A lot of medical transcription you will learn from experience but you need to at least have some good training in medical terminology.

This dictation I am going to show you is a sample of what I typically type for a clinic with general practice physicians. The S.O.A.P. format is generally used for examinations and are Subjective, Objective, Assessment, and Plan.

Anxiety, Hypertension, Hypothyroidism

09/01/07

S: Patient is doing well on current medications. She needs a TSH and basic metabolic panel to follow up her hypothyroidism and hypertension. She currently needs no refills.

O: GEN: This is a well-developed female in no acute distress.
Psychologic: Good eye contact. Good affect.
HEENT: TMs are intact bilaterally with no bulging or erythema.
Nasal mucosa is moist and pink.
Eyes: Pupils equal, round, and reactive to light.
Oropharynx: Slight cobblestoning.
Heart: Regular rate and rhythm without murmurs, rubs, or gallops.
Lungs: Clear to auscultation bilaterally without wheeze, rhonchi, or rales.
Neurologic: DTRs are 1+ at bilateral patella and Achilles. Ataxic gait noted.
Extremities: No edema.

A: Anxiety under good control.
Hypertension doing well on current medication.
Hypothyroidism doing well.

P: TSH and basic metabolic panel obtained today.
Continue current medications.
Return to clinic in two weeks for repeat BP.

PMD/mjr

D: 09/01/07
T: 09/01/07