Multiple Issues - Concise - 12/17/25 version

Subjective

[For each health issue discussed, provide a detailed but concise set of information in story format. Present each problem in its own paragraph, maintaining a narrative style. Include current symptoms, history, medication use or changes, other specialists visited, and a brief summary of any concerns related to that specific problem. Ensure that each paragraph is concise and factual, focusing on one specific problem at a time to improve readability. If more than three distinct issues are discussed, start the note with the phrase: 'This patient is a high complexity patient here for' followed by the main issues to be discussed.] For Example: [This patient is a high complexity patient here for lung transplant evaluation, diabetes management, and medication refills. Lung transplant: He reports being accepted for lung transplant and plans to relocate late January or early February. He has been accepted into the pulmonary rehab program and is awaiting further testing. He notes increased shortness of breath over the past few days, with some improvement after increasing prednisone for five days. He denies current cough. He is using a BiPAP machine, which he is still getting used to, and reports some benefit but ongoing difficulty breathing recently. He lost another 5% lung capacity and is now in the window for transplant. He is strategically limited in medication options by transplant requirements. No antibiotics being stopped; still taking Bactrim. No Trazodone or Vasopressin being held currently. Diabetes: He acknowledges his blood sugars are elevated, likely due to prednisone and possibly mycophenolate and Bactrim. He is unable to use Mounjaro and is currently managed with insulin (Lantus), with some variability in glucose readings related to travel and dietary changes. No CGM in use prior to this visit. He is due for an eye exam in January. Medication management: He requests refills for Cialis, metoprolol, omeprazole, and Zyrtec. He is unsure if his metoprolol dose is 50 mg daily or 25 mg BID; no change in dose confirmed. He continues testosterone, methadone, meloxicam, Singulair, prednisone, and Bactrim. No trouble getting medications from Tyndall pharmacy, except for a previous delay when the computer system was down. No trouble with medication refills otherwise. Other: He is not a couch potato by choice and tries to remain active, though limited by his condition. He is supported by family and is working with his grandson on household tasks. He expresses some emotional fatigue from the ongoing medical process but remains determined.]

Subjective

[For each health issue discussed, provide a detailed but concise set of information in story format. Present each problem in its own paragraph, maintaining a narrative style. Include current symptoms, history, medication use or changes, other specialists visited, and a brief summary of any concerns related to that specific problem. Ensure that each paragraph is concise and factual, focusing on one specific problem at a time to improve readability. If more than three distinct issues are discussed, start the note with the phrase: 'This patient is a high complexity patient here for' followed by the main issues to be discussed.] For Example: [This patient is a high complexity patient here for lung transplant evaluation, diabetes management, and medication refills. Lung transplant: He reports being accepted for lung transplant and plans to relocate late January or early February. He has been accepted into the pulmonary rehab program and is awaiting further testing. He notes increased shortness of breath over the past few days, with some improvement after increasing prednisone for five days. He denies current cough. He is using a BiPAP machine, which he is still getting used to, and reports some benefit but ongoing difficulty breathing recently. He lost another 5% lung capacity and is now in the window for transplant. He is strategically limited in medication options by transplant requirements. No antibiotics being stopped; still taking Bactrim. No Trazodone or Vasopressin being held currently. Diabetes: He acknowledges his blood sugars are elevated, likely due to prednisone and possibly mycophenolate and Bactrim. He is unable to use Mounjaro and is currently managed with insulin (Lantus), with some variability in glucose readings related to travel and dietary changes. No CGM in use prior to this visit. He is due for an eye exam in January. Medication management: He requests refills for Cialis, metoprolol, omeprazole, and Zyrtec. He is unsure if his metoprolol dose is 50 mg daily or 25 mg BID; no change in dose confirmed. He continues testosterone, methadone, meloxicam, Singulair, prednisone, and Bactrim. No trouble getting medications from Tyndall pharmacy, except for a previous delay when the computer system was down. No trouble with medication refills otherwise. Other: He is not a couch potato by choice and tries to remain active, though limited by his condition. He is supported by family and is working with his grandson on household tasks. He expresses some emotional fatigue from the ongoing medical process but remains determined.]

Objective

[Document physical examination findings when only when mentioned in this section, but results review for imaging should be discussed in the HPI section. Make this section only clinical bullet points related to physical exam]

Objective

[Document physical examination findings when only when mentioned in this section, but results review for imaging should be discussed in the HPI section. Make this section only clinical bullet points related to physical exam]

Assessment & Plan

[Begin with "Moderate complexity patient seen in clinic today" if 3 or fewer conditions are discussed, and "High complexity patient with total appointment time greater than 40 minutes" when more than 4 issues are discussed. Provide a summary of the most important problems in bullet format with a very brief assessment. Indicate if each condition is 'controlled', 'uncontrolled', or 'improved but not optimal'. Exclude lengthy descriptions in the plan and specifics on medication changes. Include differential diagnosis if other possible options are mentioned but do not include patient concerns as a possible diagnosis unless specifically stated as such. Separate the assessment and plan for each diagnosis. If beyond 4 important issues are discussed, summarize them much more briefly and keep them in a final section called "Other Issues Discussed"] [If weight and obesity are mentioned, add BMI diagnosis and "weight loss counseling provided today x15 minutes." If smoking is discussed and patient is a current tobacco or nicotine user, diagnose nicotine dependence and document "tobacco cessation counseling provided x5 minutes." If alcohol intake is discussed and the patient consumes alcohol daily or near daily, document alcohol dependence and "alcohol cessation counseling x10 minutes."] [If diabetes is discussed and lifestyle or medications are discussed in detail, add "Diabetes Self Management Training performed today x10 minutes"] [If PHQ-9 is discussed, document "PHQ-9 testing today performed with a score of (score). Results discussed with patient including possible changes to plan of care". Include in this paragraph patients involvement when results are discussed and their acceptance or denial of the results.] [n. Diagnosis n - maximum of 4]: - [Controlled, uncontrolled, improved but not optimal and needs further changes] - [Brief recommended treatment and management plan] - [Referral details and further assessment plans only when medically appropriate] - [Patient education and lifestyle modifications] - [Follow up details] [Other diagnoses listed in brief format with very brief summaries of topics mentioned with the instructions given to patient on "follow up in clinic if this is a persistent or worsening issue"] **Disclaimer:** This note was generated with Empathia AI (Augmented Intelligence) and may contain inadvertent errors or inaccuracies. Clinical judgment and verification should be confirmed by a licensed clinician before acting on any information contained herein.

Billing Notes

Billing Notes [Make concise notes and include CPT codes for counseling, procedures performed, and extensive visits requiring more than level 4 visits. If records request is mentioned, add "ROI" with the office or physician records needed. For procedures done in the clinic, such as liquid nitrogen cryotherapy, EKG, urinalysis, and counseling, make a single line entry for each procedure or CPT code recommended. Remove non-billable lab codes as they are performed at the lab and not billable for the clinic.] Example: - [99215 high complexity visit] - [ROI Dr. (name discussed)] - [80305 Urine Drug Screen] - [81001 Urinalysis] - [96372 knee joint injection] - [99407 tobacco cessation counseling]

Suggestions

- Document other related diagnoses that may have been overlooked but are appropriate for HCC coding. Include HCC weighting. - Include the relevant ICD10 codes and explain why they are appropriate. - Add recording time