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Streamline clinical documentation workflows with automated progress note processing. Extract SOAP format data including subjective complaints, objective findings, assessments, and treatment plans. Enable comprehensive care tracking and quality reporting.
progress-notes.pdf
Follow-up
Thomas J. Anderson
1970-05-18
MRN-2024-33456
Dr. Michelle Carter, MD
1234567890
Riverside Primary Care
Diabetes follow-up, blood pressure check
Patient returns for routine diabetes and hypertension management. Reports good compliance with medications. Checking blood sugars at home, fasting levels ranging 110-130 mg/dL. Denies polyuria, polydipsia, or blurred vision. No chest pain, shortness of breath, or lower extremity edema. Diet compliance fair - admits to occasional carbohydrate excess on weekends.
Objective
Vital signs
138/86 mmHg
72 bpm
98.4 F
16/min
198 lbs
5'10"
28.4
Physical exam
Alert, oriented, no acute distress
Regular rate and rhythm, no murmurs
Clear to auscultation bilaterally
No edema, pulses intact, monofilament exam normal
Recent labs
7.2%
126 mg/dL
1.0 mg/dL
82 mL/min
Assessment
3 items| Diagnosis | Icd10 code | Status |
|---|---|---|
Type 2 diabetes mellitus, controlled | E11.65 | Stable |
Essential hypertension | I10 | Borderline controlled |
Overweight | E66.3 | Ongoing |
Plan
6 items| Value |
|---|
Continue Metformin 1000mg BID |
Increase Lisinopril from 10mg to 20mg daily for better BP control |
Reinforce dietary counseling - limit simple carbohydrates |
Schedule diabetic eye exam |
Repeat HbA1c in 3 months |
Return visit in 3 months or sooner if concerns |
Cpt codes billed
1 item| Code | Description |
|---|---|
99214 | Office visit, established patient, moderate complexity |
25
Michelle Carter, MD
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