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Problem List

  • Essential HypertensionI10
  • Type 2 Diabetes MellitusE11.9

Active Rx

Lisinopril 10mg PO Daily
Metformin 500mg PO BID

Vitals (Today)

BP
122/78
HR
72 bpm
Comprehensive Follow-up Note✨ AI Scribed

Subjective: Patient presents for regular follow-up on hypertension and glycemic control. Reports compliance with medication and daily blood pressure logging at home.

Objective: Alert and oriented x3. Lungs clear to auscultation bilaterally. Heart rate regular rhythm without murmurs. Blood pressure well controlled today.

Assessment & Plan: 1. Hypertension - well controlled, continue Lisinopril 10mg. 2. T2D - check HbA1c in 3 months.

Auto-coded to 99214 with verified documentationReady to Sign

Billing & Codes

99214
Office Visit, Est.
$142.00
83036
HbA1c Assay
$28.00

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