Signed encounter note
Reason for visit
Cardiovascular evaluation requested before planned right-knee replacement.
Planned procedure
The orthopedic procedure is scheduled for unilateral primary osteoarthritis of the right knee. Knee treatment remains with the surgical team.
Interval history
The patient reports no new exertional chest discomfort, palpitations, or change in exercise tolerance. Blood-pressure readings and the current antihypertensive regimen are reviewed during the evaluation; essential hypertension is stable.
Cardiovascular findings
The surgeon's request and recent electrocardiogram are reviewed as part of the cardiovascular risk assessment. Cardiovascular examination is unchanged, and no new cardiac condition is identified.
Assessment and plan
Preprocedural cardiovascular examination completed. The findings are forwarded to the surgical team. Continue current hypertension therapy while proceeding with the planned evaluation pathway.
Work item details
Assignment
- Task
- Code from chart
- Assignment ID
- WRK-027
- Date of service
- 2026-11-05
- Note status
- signed
- Setting
- Outpatient physician office
Official coding reference
FY 2027
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Tabular notes
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