Signed encounter note
Reason for visit
Follow-up focused on chronic obstructive pulmonary disease and maintenance inhaler management.
Respiratory history
Breathing has been stable since the last visit. No increased dyspnea, sputum change, fever, or recent urgent respiratory care.
Findings and results
Spirometry was reviewed and shows no acute decline from prior testing. Renal laboratory trends remain stable.
Active conditions
Active problems reviewed today include hypertension and chronic kidney disease stage 3b.
Assessment and plan
COPD without acute exacerbation or lower respiratory infection. Adjust the maintenance inhaler and continue the rescue inhaler as needed. Hypertension remains under treatment; continue current therapy. Chronic kidney disease stage 3b is stable; continue renal monitoring. Return in three months for pulmonary follow-up.
Work item details
Assignment
- Task
- Code from chart
- Assignment ID
- WRK-014
- Date of service
- 2026-10-23
- Note status
- signed
- Setting
- Outpatient physician office
Official coding reference
FY 2027
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Tabular notes
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