ICD-10-CM work item

MediumFY 2027Synthetic · Educational use only

Breathing Follow-Up and History Review

Code from chart · WRK-022

Clinical chart
Signed note

Signed encounter note

DOS · 2026-10-31Assignment · WRK-022Setting · Outpatient physician office

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.