CLINIC NOTE CC: Patient Presents for Routine Examination

question 48

Short Answer

CLINIC NOTE

CC: Patient presents for routine examination

SUBJECTIVE: Sally is a 42-year-old female patient who presents today for a routine physical examination.

OBJECTIVE: BP 120/80. Pelvic exam: normal external genitalia. Vagina without discharge except for a scant amount of white discharge that appears normal. Cervix: Multiparous, clear. Bimanual exam is unremarkable. All systems are within normal limits.
ASSESSMENT:
1. Normal BP.
2. Normal pelvic exam.
Normal pelvic exam.
PLAN: Return in 1 year or as needed.
CPT Code: ____________________

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Definitions:

U.S. Army Corps

A federal agency within the Department of Defense responsible for military engineering and environmental management, including the construction and maintenance of infrastructure and flood protection.

Dredged

The process of cleaning, deepening, or widening a waterway by removing sediments and debris from the bottom.

CERCLA

The Comprehensive Environmental Response, Compensation, and Liability Act, a United States federal law designed to clean up sites contaminated with hazardous substances.

Violated

Broken or failed to comply with a rule, agreement, or law.