Signed encounter note
Reason for visit
Scheduled routine adult health examination.
Health review
The patient has no new concerns and no symptoms suggesting diabetes. There is no prior diagnosis of diabetes or prediabetes.
Examination
The general examination is completed without an abnormal finding. Immunization status and age-appropriate preventive needs are reviewed as part of the examination.
Assessment and plan
Complete routine health-maintenance counseling. Based on age and risk profile, collect a screening blood test for diabetes mellitus as a separate preventive service.
Work item details
Assignment
- Task
- Code from chart
- Assignment ID
- WRK-026
- Date of service
- 2026-11-04
- Note status
- signed
- Setting
- Outpatient physician office
Official coding reference
FY 2027
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Tabular notes
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