Signed encounter note
Reason for visit
Evaluation of a cough that began five days ago.
Interval history
The cough is intermittent and has not limited oral intake or usual activity.
Findings
Lungs are clear to auscultation, and oxygen saturation is normal on room air.
Assessment and plan
Acute cough. Encourage fluids and humidification; review return precautions for worsening or persistent symptoms.
Work item details
Assignment
- Task
- Code from chart
- Assignment ID
- WRK-005
- Date of service
- 2026-10-10
- Note status
- signed
- Setting
- Outpatient physician office
Official coding reference
FY 2027
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Tabular notes
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