Signed encounter note
Reason for visit
Type 2 diabetes follow-up with review of chronic kidney disease.
Chronic-condition review
Glucose records and the diabetes treatment plan are reviewed. Blood-pressure readings are also reviewed and remain controlled on the current regimen.
Renal findings
The renal laboratory trend is stable and remains consistent with chronic kidney disease stage 2. There is no acute change in renal function and no documented heart failure.
Assessment and plan
Type 2 diabetes mellitus with chronic kidney disease is assessed as the focus of today's visit. Hypertensive chronic kidney disease is also managed. Continue the diabetes and blood-pressure plans, monitor renal laboratory results, and follow stage 2 chronic kidney disease.
Work item details
Assignment
- Task
- Code from chart
- Assignment ID
- WRK-030
- Date of service
- 2026-11-08
- Note status
- signed
- Setting
- Outpatient physician office
Official coding reference
FY 2027
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