Signed encounter note
Reason for visit
Follow-up for chronic kidney disease management and review of renal and blood-count results.
Interval history
The patient reports taking antihypertensive medication as prescribed. No change in urine output or new bleeding concern is reported. Medication adherence, kidney function, and anemia monitoring goals were reviewed.
Findings and results
Renal laboratory trends remain consistent with chronic kidney disease stage 3b. CBC shows stable anemia, which is attributed to the chronic kidney disease.
Assessment and plan
Hypertensive chronic kidney disease, stage 3b. Continue antihypertensive therapy and renal monitoring. Anemia due to chronic kidney disease is stable; continue the current anemia management plan and repeat CBC with the next renal panel.
Work item details
Assignment
- Task
- Code from chart
- Assignment ID
- WRK-015
- Date of service
- 2026-10-24
- Note status
- signed
- Setting
- Outpatient physician office
Official coding reference
FY 2027
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