Signed encounter note
Reason for visit
Evaluation of nausea.
Interval history
Nausea began two days ago without vomiting. The patient is able to tolerate fluids and reports no fever or focal abdominal pain.
Examination
The abdomen is soft and nontender without guarding; hydration appears adequate.
Assessment and plan
Nausea without vomiting; etiology remains undetermined. Provide supportive care and return precautions for worsening symptoms or new vomiting.
Work item details
Assignment
- Task
- Code from chart
- Assignment ID
- WRK-018
- Date of service
- 2026-10-27
- Note status
- signed
- Setting
- Outpatient physician office
Official coding reference
FY 2027
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Tabular notes
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