Signed encounter note
Reason for visit
Evaluation of new respiratory symptoms in a patient with COPD.
Interval history
Cough and increased sputum began four days ago, with fatigue and intermittent fever. Breathing is not acutely worse than the patient's usual COPD baseline, and there has been no increased rescue-inhaler use.
Findings
Chest imaging shows a new infiltrate consistent with pneumonia; no causative organism is identified.
Medication status
The medication list confirms a daily inhaled corticosteroid used as long-term therapy.
Assessment and plan
The visit addresses pneumonia, organism unspecified, and COPD with acute lower respiratory infection; no acute COPD exacerbation is present. Begin antibiotic treatment for pneumonia, review respiratory precautions, and continue the maintenance inhaler.
Work item details
Assignment
- Task
- Code from chart
- Assignment ID
- WRK-029
- Date of service
- 2026-11-07
- Note status
- signed
- Setting
- Outpatient physician office
Official coding reference
FY 2027
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