CLINIC NOTE CC: Patient Presents for Routine Examination

question 11

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.
PLAN: Return in 1 year or as needed.
CPT Code: ____________________

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