The post Schizophrenia Discharge Summary Transcription Sample Report appeared first on Medical Transcription Phrases, Words, And Helpful Hints.

Transfer of Care Medical Transcription Sample Report #1

TRANSFER DIAGNOSES:
1. Upper gastrointestinal bleeding secondary to duodenal ulcer in the setting of nonsteroidal anti-inflammatory drugs and steroid use, status post EGD.
2. Anemia, status post packed red blood cells transfusion.

SECONDARY DIAGNOSES:
1. Hypertension.
2. Hyperlipidemia.
3. Osteoarthritis, chronic back and hip pain.
4. History of renal calculi.
5. Dementia with baseline significant confusion.

PAST SURGICAL HISTORY: Appendectomy in the past.

PROCEDURES: Upper endoscopy revealing bleeding duodenal ulcer, treated with epinephrine injection and BICAP which achieved hemostasis.

REASON FOR ADMISSION: Dark tarry stools.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old woman who presented to the emergency room complaining of dark tarry stool. She recently, prior to admission, had been treated with steroids for sciatica and hip pain. Also has been taking NSAIDs for her osteoarthritis and the low back pain as well as baby aspirin for coronary artery disease prophylaxis.

The patient on admission to the emergency room was noted to have a hemoglobin of 11.7 and hematocrit of 34.2 with stable hemodynamics. Systolic blood pressure 153, diastolic 96. Rectal exam was performed in the emergency room revealing black stool, melena. The patient was taken to the procedure suite where she has undergone upper EGD, which revealed a bleeding duodenal ulcer, which was treated with epinephrine and BICAP. Hemostasis was achieved.

The patient was transferred to the intensive care unit for further observation given upper gastrointestinal bleeding.

PHYSICAL EXAMINATION: On admission to the intensive care unit, blood pressure 156/76, heart rate 74, oxygen saturation 100% on 2 liters, temperature 98.2, respiratory rate 18. General: A pleasant elderly-appearing female, alert and oriented only to self and place, not to time. Head and Neck: Unremarkable. Pupils equal, round and reactive to light and accommodation. Extraocular muscles intact. Oral mucosa moist. No oropharyngeal exudate. Chest: Clear to auscultation bilaterally with good respiratory excursion. Cardiovascular: Normal S1 and S2. No murmurs. Abdomen: Soft, nontender, nondistended with positive active bowel sounds. No guarding, no rebound tenderness. Extremities: Warm without clubbing, cyanosis or edema.

PAST MEDICAL HISTORY: As above.

HOME MEDICATIONS:
1. Metoprolol XL 100 mg orally daily.
2. Aspirin 81 mg orally daily.
3. Aricept 10 mg orally day.
4. Simvastatin 20 mg orally daily.
5. Tramadol 50 mg orally daily p.r.n. for pain.
6. Dyazide 50/25 mg orally daily.
7. Etodolac 400 mg p.o. t.i.d.

ALLERGIES: The patient reports allergies to vancomycin and atorvastatin.

SOCIAL HISTORY: The patient is a nonsmoker, nondrinker. She is married. All children are healthy. She lives with her husband who takes care of her. The patient is baseline demented.

HEALTH MAINTENANCE: Last colonoscopy in (XXXX).

FAMILY HISTORY: Positive for coronary artery disease in father. No history of cancers, including colon cancer or stomach cancer.

LABORATORY DATA: On discharge from the intensive care unit, white blood cell count 6.64, hemoglobin 11.4, hematocrit 33.2, platelet count 109,000, MCV 92. Sodium 144, potassium 3.5 (this was repleted), chloride 115, bicarbonate 25, BUN 12, creatinine 0.7, glucose 101, calcium 8, magnesium 2.2, phosphate 2.6. INR 1.1, PTT 25. Her MRSA screen and VRE screen obtained upon ICU admission were both negative.

HOSPITAL COURSE BY ISSUE: This is a (XX)-year-old female who was admitted to the intensive care unit for further observation after undergoing EGD to achieve hemostasis for bleeding duodenal ulcer.
1. Gastrointestinal bleeding. The patient is status post EGD. Hematocrit was monitored initially every 8 hours, remained stable, ranges from 31 to 33 for the last 48 hours. The patient did not have any bloody or black stools any longer. She was initiated on Protonix drip after a bolus of Protonix was given. Upon transfer to the floor, the patient will be switched to IV Protonix 40 mg b.i.d. Hematocrit can be checked now twice a day. The patient was recommended to avoid NSAIDs and diet had been advanced to clear liquids as tolerated.
2. Anemia, requiring blood transfusion. The patient has been transfused 2 units, hematocrit monitored as above. The patient started on iron sulfate in the intensive care unit, 325, may continue on the floor for a week but not strongly indicated.
3. Baseline dementia. The patient was agitated on the first night of the admission to the intensive care unit and was confused, disoriented, pulling on lines, gowns and blankets. She was diagnosed with ICU delirium. She was taking her trazodone as at home for insomnia without effect. She was given Seroquel 25 mg for ICU delirium treatment. That did not prove to be effective for her. She required further administration of 1 mg IV Haldol with good effect. The patient slept overnight. She was continued on her home dose of Aricept, that should be continued on the floor. Haldol can be used in small doses p.r.n. since the patient is very sensitive. EKG can be checked to ensure no QT prolongation develops. Her last EKG showed QTc of 487 msec, which is slightly prolonged.
4. Hyperlipidemia. The patient was continued on simvastatin on her home dose regimen.
5. Hypertension. On the second day of admission to the intensive care unit, her blood pressure had persistently been elevated to over 130 to 140 systolic. Given that initially both antihypertensive medications have been held for possibility of hemodynamic instability secondary to gastrointestinal bleeding, we are restarting her metoprolol 25 mg orally twice a day. Smaller dose than patient takes at home to date. That dose might be increased. Also, the patient should be monitored for signs of GIB, although, her hematocrit remains stable. The patient could be restarted on her dose of Dyazide if no further hemodynamic issues arise tomorrow.
6. For DVT prophylaxis, the patient had Venodynes on while she was in the intensive care unit. She has been on Protonix drip, which has been switched to IV Protonix b.i.d. Fluids at this time remain saline locked. Electrolytes will be repleted as needed.
7. Nutrition: The patient should continue on clear liquid diet, which could be advanced slowly on the floor and further per GI recommendations.
8. Resuscitation: CODE STATUS is full.

Family has been updated by the ICU team. The patient’s husband is actively participating in her care.

Transfer of Care Medical Transcription Sample Report #2

REASON FOR ADMISSION: Upper gastrointestinal bleed.

DISCHARGE DIAGNOSIS: Upper gastrointestinal bleeding, status post EGD.

DISCHARGE MEDICATIONS:
1. Metoprolol 50 mg orally twice a day, hold for systolic blood pressure less than 100, heart rate less than 60.
2. Warfarin 2.5 mg p.o. daily.
3. Heparin drip at 18 units/kg per hour.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old woman with history of prosthetic aortic valve and mitral valve who is on Coumadin and Lovenox who has been admitted via the emergency room where she came in complaining of maroon-colored stools of 1 day’s duration. The patient did have EGD.

At that time, a 2 cm sessile polyp had been removed from the antral portion of her stomach. The patient was hemodynamically stable and was discharged to home. While she was observed in the emergency room, her hematocrit was 30.9 and she had been hemodynamically stable, also slightly tachycardic with a heart rate of 106.

She was admitted to the telemetry floor for further observation and monitoring of her gastrointestinal bleed. At 1:45 a.m., the patient went to the commode to have a bowel movement and had an unconscious episode. Code Blue was called to her room. The patient regained consciousness almost immediately. She was found to have vomited dark clots, and NG tube placed to suction produced copious amounts of dark clotted blood. The patient has been hemodynamically stable through the event and has been transferred to the intensive care unit for further observation.

PAST MEDICAL HISTORY:
1. Hyperlipidemia.
2. History of mitral valve replacement and aortic valve replacement.
3. History of paroxysmal atrial fibrillation.
4. History of hypertension.
5. History of ankle injury many years ago.
6. Osteoarthritis.
7. Hypothyroidism.
8. Osteoporosis.

ALLERGIES: No known drug allergies.

HOME MEDICATIONS:
1. Metoprolol 100 mg p.o. b.i.d.
2. Hydrochlorothiazide 25 mg p.o. daily.
3. Coumadin 2.5 mg daily.
4. Lovenox 150 mg daily.
5. Lipitor 20 mg daily.
6. Levothyroxine 25 mcg p.o. daily.
7. Vitamin D 1000 units daily.
8. Calcium 1 tablet daily.
9. Travatan eye drops once a day.

SOCIAL HISTORY: The patient lives with her husband. She is independent in activities of daily living. She does not smoke tobacco and has no reported alcohol or drug use.

PHYSICAL EXAMINATION: On discharge, the patient is alert and oriented to person, place and time. A pleasant elderly female who is lying in bed. NG tube discontinued today. Head and neck exam normal. Pupils equal, round, reactive to light and accommodation. Extraocular muscles intact. Cranial nerves II through XII intact. Cardiovascular exam reveals normal S1 and S2. There is murmur consistent with prior valves replacement. Lungs: Clear to auscultation bilaterally. Abdomen: Obese, soft, nontender, nondistended with very active positive bowel sounds. Extremities: Warm. No edema. Pedal pulses 2/4 bilaterally in all 4 extremities. Skin is intact. The patient is on 2 liters of nasal cannula oxygenation.

Vital signs at discharge; temperature 98.6, blood pressure 133 to 144 systolic, 44 to 70 diastolic. Heart rate 85 to 95, respiratory rate 16, oxygen saturation 98 to 100% on 2 liters. Urine output 50 to 75 mL an hour. The patient’s cumulative balance is positive, about 2300 mL since last 24 hours.

LABORATORY DATA: On discharge, white blood cell count 11.2, hemoglobin 9.2, hematocrit 26.8. Last hematocrit was 30, platelet count 193,000. MCV 88, sodium 140, potassium 3.1, which was repleted. Sodium 109, bicarbonate 28, BUN 21, creatinine 0.8, glucose 107, calcium 7.5, magnesium 1.5, that was repleted, phosphate 2.7. INR 2.1, PTT 155. Blood glucose was varying, 111 to 112 in the last 24 hours.

ASSESSMENT: This is a (XX)-year-old woman with upper gastrointestinal bleed, on anticoagulation, status post removal of 2 cm sessile polyp from her stomach, status post EGD showing clean base gastric ulcer with no bleeding.
1. Upper gastrointestinal bleed. The patient had an EGD, which showed clean ulcer without any evidence of bleeding. The patient was given erythromycin to empty the stomach, IV. The patient was transfused a total of 3 units of packed red blood cells since admission. Last transfusion was overnight. Last hematocrit value was 30. The patient should be transfused to goal hematocrit of over 30. She completed PPI, Protonix drip and now switched today to Protonix 40 mg IV b.i.d.
2. History of MVR and AVR. The patient needs anticoagulation. She has been seen by Cardiology in consult yesterday. Recommended to keep on heparin drip until INR is therapeutic. Coumadin was restarted today at 2.5, which is her home dose. The patient should be monitored for signs of GI bleeding, and heparin drip should be stopped immediately if any signs of GI bleeding occurred again.
3. Hypertension. The patient will continue her home dose medication. Blood pressure is well controlled. Heart rate is well controlled again, given the patient’s beta blockers recently for other signs of GI bleeding.
4. Hyperlipidemia. The patient will continue on Lipitor.
5. Paroxysmal atrial fibrillation. The patient has been in normal sinus rhythm since admission to intensive care unit. Did not require any antiarrhythmic administration.
6. Hyperglycemia. The patient has borderline hyperglycemia. We initially placed on NovoLog insulin sliding scale, but it was discontinued since blood glucose over the last 24 to 48 hours has never been over 120. Should be monitored daily if needed.
7. Question of sleep apnea. The patient is snoring all night and has occasional episodes of desaturation to lower 90s. Maybe needs a sleep study to be evaluated for sleep apnea.
8. Nutrition. The patient remains n.p.o. This was discussed with GI doctor. Diet could be advanced to clear liquids again. Please notify GI once advancement of diet.
9. For DVT prophylaxis, the patient is currently on heparin drip. For PPIs, she is on Protonix IV b.i.d. Fluids at this time remain at KVO. Electrolytes should be repleted on as-needed basis.
10. Resuscitation. CODE STATUS is full. The patient’s next of kin is her husband.

The post Transfer of Care Medical Transcription Sample Reports appeared first on Medical Transcription Phrases, Words, And Helpful Hints.

Pediatric Discharge Summary Medical Transcription Sample Report #1

DATE OF ADMISSION: MM/DD/YYYY

DATE OF DISCHARGE: MM/DD/YYYY

ADMITTING DIAGNOSES:

1. A 28-week gestational male, twin A.
2. Discoordinate twin.
3. Intrauterine growth restriction.
4. Prolonged premature rupture of membranes.
5. Respiratory depression.
6. Hypotonia secondary to magnesium therapy.

DISCHARGE DIAGNOSES: Per discharging physician.

REASON FOR ADMISSION: Respiratory depression requiring intubation.

HISTORY OF PRESENT ILLNESS:

This patient is the twin A of a 28-week gestation twin pregnancy of a (XX)-year-old prima gravida with an estimated date of confinement of MM/DD/YYYY, which gives an estimated gestational age of 28 weeks. Mother is blood type O positive, hepatitis B, gonorrhea, Chlamydia, HIV and VDRL negative. Pregnancy was complicated with twin gestation with one discoordinate twin; this is the undergrown baby. The mother had rupture of membranes on MM/DD/YYYY, approximately 20:30 in the evening. Estimated fetal weight was approximately 910 grams. Mother was admitted to the hospital and treated with tocolysis with magnesium sulfate and terbutaline as well as antibiotic prophylaxis on ampicillin and erythromycin. She did complete a full course of betamethasone on MM/DD/YYYY. She continued to progress in labor despite tocolytics, and it was elected to allow her to continue to delivery. Cesarean section was done secondary to a breech presentation. Apgar scores were 4 at one minute and 7 at five minutes. In the delivery room, the baby was noted to be very slim with poor tone and poor respiratory effort. The color did not improve with oxygen and stimulation. There was a short course of mask CPAP followed quickly by elective intubation with a 2.5 endotracheal tube. Following intubation, the color and activity did improve and the infant was transported to the neonatal intensive care unit.

PHYSICAL EXAMINATION: On admission revealed a grossly normal-appearing, undergrown, preterm male with respiratory failure. Birth weight was 790 grams. Birth length was 34 cm. Birth head circumference was 23.4 cm, which is AGA for gestational age. Vital Signs: Pulse 120, respirations 60, blood pressure 61/33 and temperature 35.1. Skin was pink with acrocyanosis. HEENT is normocephalic. Anterior fontanelle is open and soft, features normal. Eyes, ears, nose and mouth appear grossly normal. Red reflex bilaterally. Neck appears normal with no visible masses. Chest symmetrical with diminished breath sounds bilaterally. Few rales noted. Cardiovascular: Regular rate and rhythm. No murmurs. Peripheral pulse is palpated. Abdomen had three-vessel cord. Positive bowel sounds. No palpable organomegaly or mass. GU is normal male with testes present but not descended to the scrotum, which is appropriate for gestational age. Anus appeared patent. Musculoskeletal: No obvious deformation or abnormalities noted. Neurologic: The patient is responsive with symmetrical movements and moderate tone.

HOSPITAL COURSE BY SYSTEMS:
1. NEUROLOGIC: Cranial ultrasound performed on MM/DD/YYYY showed a small left subependymal hemorrhage with no intraventricular hemorrhage. This was repeated on MM/DD/YYYY, which showed a small left subependymal hemorrhage that was resolving. Eye examination performed on MM/DD/YYYY showed some immature vessels into zone II. This was repeated on MM/DD/YYYY by Dr. Doe, which showed the immature vessels into zone II and no retinopathy of prematurity noted. This will be followed up in approximately two weeks to reevaluate. Hearing screen is pending. Clinically, the child has remained neurologically stable with good tone, good activity, moving all extremities, and no abnormalities have been noted to date.

2. CARDIOVASCULAR: Echocardiogram on MM/DD/YYYY revealed a patent ductus arteriosus. This was followed with indomethacin x3 doses. Repeat echocardiogram on MM/DD/YYYY showed no patent ductus arteriosus and resolution. The child did have some initial hypotension, which required dopamine, which was initiated on MM/DD/YYYY and continued through MM/DD/YYYY; the last several days being very low dose dopamine to increase renal perfusion. The pressure has stabilized with good perfusion and cardiovascularly stable. However, on MM/DD/YYYY, murmur was again auscultated on the left upper and lower sternal borders. Repeat echocardiogram revealed a very large patent ductus arteriosus with enlargement of the left atrium. Please see that dictation. Due to the previous Indocin therapy failure, it was elected to have PDA ligation. This was performed on MM/DD/YYYY by Dr. Doe. Please see his dictation. Following that procedure, the infant had some hypotension requiring dopamine, low dose. This was slowly increased over the next following two or three days. By MM/DD/YYYY, dobutamine was added secondary to decreasing pressures. Epinephrine was kept at the bedside; however, it was never used. Dopamine and dobutamine were continued until MM/DD/YYYY at which time they were weaned off, and the child has maintained pressure since that time with good clinical examination and blood pressure remaining 36-48.

3. RESPIRATORY: The infant was intubated in the delivery room secondary to respiratory depression. The infant has remained ventilated to this date. Originally, on SIMV conventional, was switched to a jet ventilator on MM/DD/YYYY and back to conventional SIMV on MM/DD/YYYY. Has remained on this mode since that time. Initial venous blood gas obtained on the day of admission was pH of 7.32, pCO2 50, pO2 of 52, bicarbonate 28.1 and base excess of 2.1. Blood gas prior to changing to the jet ventilator was pH 7.21, pCO2 of 74, pO2 65, bicarbonate 27.1, and base excess -0.3. Following the jet ventilator, switching back to conventional, pH was 7.24, pCO2 of 44, pO2 of 51, bicarbonate 19.9, and base excess -6.6. The infant has continued to require significant ventilatory support and has been somewhat problematic with elevated pCO2; however, has been maintained on adequate oxygenation over that time. This is thought to be secondary to the BPD this child would obviously be developing secondary to its premature age of birth and the prolonged exposure to the ventilator and oxygen. Following admission to the NICU, there were two doses of Curosurf that were administered shortly after admitted to the NICU. Several episodes of apnea and bradycardia were noted. Early on the course, there had been no apnea or bradycardia noted, in the last approximately 25 days. At the time of this dictation, the infant is currently on SIMV pressure support. Peak inspiratory pressure of 25. Post end expiratory pressure of 6, pressure support of 14, rate of 38. Latest capillary blood gas shows a pH of 7.30, pCO2 64, pO2 34, bicarbonate 31.5, and a base excess of 5.6 and a FiO2 of 50%. The remainder of the ventilatory course will be addressed by the discharging physician.

4. INFECTIOUS DISEASE: Blood culture was obtained on the date of admission; shows no growth. Ampicillin and gentamicin were initiated on the admission as well and discontinued at 48 hours secondary to negative cultures. On MM/DD/YYYY, endotracheal aspirate was obtained, which showed heavy growth of Enterobacter cloacae. Cefotaxime antibiotic was initiated. A repeat of the endotracheal aspirate on MM/DD/YYYY revealed heavy growth of Enterobacter cloacae that was resistant to cefotaxime, and at that time, gentamicin was added for synergism. A repeat endotracheal aspirate on MM/DD/YYYY continued to show the persistence of Enterobacter cloacae with sensitivity to cefotaxime, gentamicin and cefepime. It was elected to treat with monotherapy cefepime, and this is most likely due to colonization of the endotracheal tube. Dr. Doe of Infectious Disease was consulted and has been following the patient. Blood culture on MM/DD/YYYY with no growth. Blood culture from MM/DD/YYYY revealed Candida parapsilosis. Amphotericin B was initiated. The infant tolerated the trial dose, and treatment dose was initiated the following day, on MM/DD/YYYY. The amphotericin was continued until MM/DD/YYYY at which time it was discontinued. Repeat blood culture on MM/DD/YYYY revealed Candida parapsilosis. Blood culture from MM/DD/YYYY with no growth. It was of this blood culture that the time frame for discontinuing the amphotericin B was established. On identification of the candidemia, a spinal tap was performed with cerebrospinal fluid for culture, which was plated on MM/DD/YYYY. There was no growth and no fungus isolated. Cefepime therapy was continued for the Enterobacter until MM/DD/YYYY at which time it was discontinued. At the time of this dictation, the patient is currently on no antibiotics.

5. HEMATOLOGY: The patient’s blood type is O positive, Coombs negative. The infant was noted early on in the admission to be jaundiced. Phototherapy was initiated on MM/DD/YYYY and discontinued on MM/DD/YYYY. Peak bilirubin was 7.1 mg/dL. The last bilirubin obtained, MM/DD/YYYY, showed a total bilirubin of 3.8, conjugated 2.3, and unconjugated 1.4. The infant has been anemic on several occasions and has received four transfusions of packed red blood cells on MM/DD/YYYY, MM/DD/YYYY, MM/DD/YYYY and MM/DD/YYYY. Initial CBC on MM/DD/YYYY showed a white blood cell count of 4.5, hemoglobin of 17.4, hematocrit of 51.1, and platelets of 202,0000. Following identification of the candidemia, the infant had a marked thrombocytopenia. On MM/DD/YYYY, the CBC showed a white count of 3800, hemoglobin 12.1, hematocrit 34.7, and platelets 27,000. This decreased to the low on MM/DD/YYYY, which showed 12,000 platelets. The child received three transfusions of platelets during this time, which slowly increased the platelets. The final CBC obtained MM/DD/YYYY to date showed a white count of 7700, hemoglobin 13.2, hematocrit 37.4 and platelets at 49,500. Differential; polymorphonuclear cells 50%, bands 2%, lymphocytes 42%, and monocytes 6%. The anemia this child has developed is most likely secondary to prematurity and iatrogenic blood draws. No other hematologic source had been identified to date.

6. HEALTHCARE MAINTENANCE: Birth weight was 790 grams, birth head circumference was 23.4 cm, and birth length was 35 cm. The patient was initially NPO with IV fluids and D10W. TPN was initiated on MM/DD/YYYY and has been continued to date. Enteral feeds of premature infant male via NG tube were started on MM/DD/YYYY. They have been slowly increased until the PDA ligation at which time the infant was NPO for several days. Enteral feeds were again reinitiated on MM/DD/YYYY and it has slowly been increased. At the date of this dictation, the infant is currently on 13 mL q.3 h. and tolerating well. Nippling has not been attempted to date secondary to endotracheal tube.

IMMUNIZATIONS: Per discharging physician.

PROCEDURES: Umbilical artery catheter and umbilical venous catheter were inserted on MM/DD/YYYY and discontinued on MM/DD/YYYY. PDA ligation was performed on MM/DD/YYYY.

DISCHARGE PLAN WITH DISPOSITION: Per discharging physician.

Pediatric Discharge Summary Medical Transcription Sample Report #2

DATE OF ADMISSION: MM/DD/YYYY

DATE OF DISCHARGE: MM/DD/YYYY

ADMITTING DIAGNOSES:
1. Intrauterine pregnancy at 36 weeks.
2. Twin gestation.
3. Breech presentation of twin A.

DISCHARGE DIAGNOSES:
1. Intrauterine pregnancy at 36 weeks.
2. Twin gestation.
3. Breech presentation of twin A.
4. Status post primary low transverse cesarean section for malpresentation of twins.

CHIEF COMPLAINT: At the time of admission, contractions.

HISTORY: The patient is a (XX)-year-old gravida 1 at 36 weeks with known twins with contractions and good fetal movement, no bleeding, no loss of fluids.

OB HISTORY: Present pregnancy with previous receipt of a steroid window.

GYN HISTORY: Significant for chlamydia, which was treated.

MEDICAL HISTORY: Unremarkable.

MEDICATIONS: Prenatal vitamins.

ALLERGIES: None.

SURGICAL HISTORY: None.

SOCIAL HISTORY: No drinking, smoking or drug use. No domestic violence. The father of the baby is currently involved, and the patient is living with a friend.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature is 36.2, pulse 88, respirations 18 and blood pressure 121/58.
HEART: Regular rate and rhythm.
LUNGS: Clear.
ABDOMEN: Soft and gravid.
VAGINAL: Exam 4, 100 and bulging bag of water.
Baby A had tones in the 130s plus accels, no decels. Baby B had tones in the 150s with accels and no decels. Tocometer showing every 5-minute contractions. The plan was to admit the patient and proceed with cesarean section.

HOSPITAL COURSE: Postoperatively, the patient did well. She was eating, ambulating and voiding, passing gas by postoperative day #2, and on postoperative day #3, she continued to do well. She had been seen by Social Work and options made aware to the patient. She was ready for discharge. She remained afebrile throughout her hospital course.

DISCHARGE INSTRUCTIONS: She will be discharged to home to follow up in two weeks for a wound check.

MEDICATIONS AT THE TIME OF DISCHARGE: Percocet, Motrin and Colace.

Pediatric Discharge Summary Medical Transcription Sample Report #3

DATE OF ADMISSION: MM/DD/YYYY

DATE OF DISCHARGE: MM/DD/YYYY

BRIEF HISTORY:
The infant was born approximately 11:00 a.m. on MM/DD/YYYY to her (XX)-year-old gravida 4, para 4, abortion 0, O positive mother. EDC was MM/DD/YYYY. There was no premature rupture of membranes. Amniotic fluid was clear. Delivery was by C-section because of repeat C-section. Spinal anesthesia was used. Apgars were 9 and 9. Upon arrival at the nursery, gestational age was 39 weeks by dates, 39 weeks by exam. Birth weight was 6 pounds 2 ounces or 2780 grams. Length was 18.5 inches or 47 cm. OFC 32 cm.
PHYSICAL EXAMINATION: On admission revealed a term appropriate for gestational age infant with milia, salmon patches over the eyes and speckles over the glabella and the philtrum, 1.4 cm breast buds bilaterally. No Epstein pearls. Hips within normal limits.

HOSPITAL COURSE: Throughout hospitalization, the infant did well. The infant was bottle fed and was taking about 2 ounces per feed upon discharge. The infant was not gaining weight with a discharge weight of 5 pounds 16 ounces. There was jaundice noticed during hospitalization. Mother’s blood type was O positive. The infant’s blood type was A positive with weakly positive direct Coombs. Bilirubin level on MM/DD/YYYY came back 7.6. Bilirubin level on MM/DD/YYYY came back 8.3. The infant did not appear to be becoming any more jaundiced and no further bilirubin level levels were done. Mother did have a car seat available upon release. The infant had passed her hearing screen. The infant had received the hepatitis B vaccine on MM/DD/YYYY. Mother was released on MM/DD/YYYY. Discharge physical exam of the infant was unremarkable and it was felt that the infant could be released to her mother.

DISCHARGE DIAGNOSES:

1. Term newborn female.

2. ABO incompatibility with positive direct Coombs.

3. Hyperbilirubinemia.

4. Salmon patch.

5. Milia.

6. Not gaining weight.

7. Hearing screen passed.

8. Hepatitis B vaccine given.

DISPOSITION: The infant was released to her mother. Mother is to call me if she had any problems or appeared to be becoming any more jaundiced. Mother was to bring her back in two days for the nursery nurses to recheck her and bring her back to my office in about a week for me to check. If there are any problems before that time, she is to get in touch with me by phone.

The post Pediatric Discharge Summary Medical Transcription Sample Report appeared first on Medical Transcription Phrases, Words, And Helpful Hints.