Signed encounter note
Reason for visit
Scheduled follow-up for chronic obstructive pulmonary disease.
Interval history
Breathing remains at baseline with no recent increase in cough, sputum, or rescue-inhaler use.
Tobacco history
The patient quit cigarettes several years ago and has no current tobacco use; personal history of nicotine dependence is reviewed today.
Findings
Examination shows nonlabored breathing and no new focal lung finding.
Assessment and plan
COPD is stable without acute exacerbation or lower respiratory infection. Continue the current maintenance inhaler and routine follow-up.
Work item details
Assignment
- Task
- Code from chart
- Assignment ID
- WRK-022
- Date of service
- 2026-10-31
- Note status
- signed
- Setting
- Outpatient physician office
Official coding reference
FY 2027
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Tabular notes
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