Signed encounter note
Reason for visit
Same-day evaluation for sore throat and painful swallowing.
Interval history
Symptoms began two days ago, and the patient is able to drink fluids despite throat discomfort. Pain is worse with swallowing and has not improved with warm liquids.
Findings and test results
The pharynx is erythematous without peritonsillar swelling. A rapid group A streptococcal test is positive.
Assessment and plan
Streptococcal pharyngitis. Start the prescribed oral antibiotic. Use fluids, warm salt-water gargles, and an over-the-counter analgesic as needed for throat discomfort.
Work item details
Assignment
- Task
- Code from chart
- Assignment ID
- WRK-010
- Date of service
- 2026-10-17
- Note status
- signed
- Setting
- Outpatient physician office
Official coding reference
FY 2027
Use the Alphabetic Index to identify a candidate, then verify its description, hierarchy, and reportability in the Tabular List.
The unified Index and code lookup remains available in the Code tab. Reference use is not counted as assistance.
Tabular notes
Review Excludes, Code first, Code also, specificity, laterality, and required characters before submitting.
Open official CDC Index & Tabular