Signed encounter note
Reason for visit
Follow-up for type 2 diabetes and chronic kidney disease.
Interval history and medications
The home glucose log was reviewed, and no hypoglycemic episodes are reported. The patient continues basal insulin every day as established long-term therapy. Medication reconciliation confirms no oral glucose-lowering or injectable non-insulin medication.
Renal results
Serial renal laboratory results show no acute decline. Kidney function remains stable at chronic kidney disease stage 3a; dialysis is not planned or performed.
Assessment and plan
Type 2 diabetes mellitus with diabetic chronic kidney disease. Chronic kidney disease stage 3a is stable. Continue daily basal insulin, nutrition plan, home glucose monitoring, and renal surveillance.
Work item details
Assignment
- Task
- Code from chart
- Assignment ID
- WRK-012
- Date of service
- 2026-10-21
- Note status
- signed
- Setting
- Outpatient physician office
Official coding reference
FY 2027
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