CLINIC NOTE CC: Patient Presents for Routine Examination

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: ____________________