Signed encounter note
Reason for visit
Scheduled annual general medical examination without an acute complaint.
Preventive review
Medication use, nutrition, activity, and recommended preventive services were reviewed as part of the examination.
Findings
Current A1c and the home glucose log remain above the individualized target. No hypoglycemic episodes are reported.
Medications
Basal insulin is used every day as established long-term therapy. Medication reconciliation shows no oral glucose-lowering or non-insulin injectable medication.
Assessment and plan
Annual general medical examination completed with abnormal findings. Type 2 diabetes mellitus with hyperglycemia was evaluated during the visit. Adjust basal insulin and continue home monitoring; follow up in three months.
Work item details
Assignment
- Task
- Code from chart
- Assignment ID
- WRK-013
- Date of service
- 2026-10-22
- Note status
- signed
- Setting
- Outpatient physician office
Official coding reference
FY 2027
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Tabular notes
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