S — Subjective
AI Generated
60 y/o male, chest tightness on exertion × 3 weeks. Denies rest pain, palpitations, syncope. Mild DOE. Current meds: Lisinopril 10mg, Atorvastatin 40mg.
O — Objective
AI Generated
HR 78, SpO₂ 97%, Temp 98.4°F, RR 16. CV: RRR, no murmurs/rubs/gallops. Lungs CTA bilaterally. No edema. EKG: NSR, no ST changes.
⚠ O — Blood Pressure
Required · Missing
⚠ BP reading required for all cardiology notes. Must complete before submission.
🎙️ Tap to fill → "One forty over eighty-eight" → 140/88 mmHg
A — Assessment
AI Generated
Exertional chest tightness with CV risk factors. Consistent with possible stable angina. R/O significant CAD. EKG unremarkable at rest.
P — Plan
AI Generated
1. Stress test ordered. 2. ASA 81mg daily. 3. Cardiac imaging if positive. 4. Continue antihypertensive + statin. 5. Return if rest pain. 6. F/U 2 weeks.
▸ Real-Time Coding Suggestions
ICD-10
I20.9
Angina pectoris, unspecified
0.94 ✓
ICD-10
I10
Essential hypertension
0.99 ✓
CPT
99213
Office visit, established, moderate complexity
0.91 ✓
MIPS
MIPS 226
Tobacco screening & cessation
0.88 ✓