Signed encounter note
Reason for visit
Follow-up for asthma and seasonal nasal symptoms.
Interval history
Breathing is at baseline without an acute flare. Nasal congestion, sneezing, and clear drainage recur on high-pollen days each spring and have interfered with sleep over the past week.
Assessment and plan
Moderate persistent asthma without acute exacerbation; continue controller therapy and review inhaler technique. Seasonal allergic rhinitis due to pollen. The nasal condition is managed as a problem distinct from the asthma; start daily intranasal therapy during pollen season.
Work item details
Assignment
- Task
- Code from chart
- Assignment ID
- WRK-008
- Date of service
- 2026-10-15
- Note status
- signed
- Setting
- Outpatient physician office
Official coding reference
FY 2027
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Tabular notes
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