Controller Medication Follow-Up

Code from chart · WRK-023

Clinical chart

Signed note

Signed encounter note

DOS · 2026-11-01Assignment · WRK-023Setting · Outpatient physician office

Reason for visit

Follow-up for asthma and controller-medication management.

Interval history

Symptoms have been controlled on the current regimen, with no urgent visits, nighttime awakening, or recent flare. There has been no need for oral steroid treatment.

Findings

Breathing is unlabored, and no wheezing is heard on examination.

Medications and status

The patient uses a daily inhaled corticosteroid as long-term therapy and reports taking it consistently.

Assessment and plan

Mild persistent asthma is uncomplicated today. Continue the daily inhaled corticosteroid and use the rescue inhaler as needed.

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