My transcription sample - audio attached

by josephkisaac

SUBJECTIVE:This white pleasant 25-year-old female complains of cough and chest congestion that has worsened over the last week.She also has chronic sinus and nasal allergy symptoms.She has tried a nasal steroid with some success in the past.She has no significant fever at this time. She has no known drug allergies. OBJECTIVE:Blood pressure:100/68.Pulse:88.Respirations:20.Temperature:98.2. Weight:118 pounds.GENERAL:In no acute distress.Mucous membranes are moist and pink.Nares are mildly erythematous with some white drainage on the right. Sinuses are nontender.Conjunctivae are mildly injected.TMs are retracted.There is no cervical adenopathy.Heart is regular.Lungs are mildly coarse on expirations.There are no crackles or overt wheezes. ASSESSMENT: 1.Acute bronchitis. 2.Allergic rhinitis. PLAN: 1.Doxycycline 100 mg b.i.d. for 10 days. 2.Flonase one to two sprays in each nostril daily. 3.Recheck above in two weeks or sooner if the condition worsens or if symptoms persist.

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I'm an editor in medical transcription industry. I have transcribed and edited reports ranging from orthopedics, gastroenterology, podiatry, psychiatry, OB/GYN, surgical reports, etc. My responsibility is to deliver quality reports and which I am doing consistently.

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