Live encounter · in progress
Marquez, Jose · 67M · DM2/HTN/CKD3 · MRN 4419873
Elapsed
00:14:32
JM
Marquez, Jose
MRN 4419873
Active conditions
DM2 (uncontrolled)
HTN st 2
CKD3
MDD
OSA
CMP
Vitals · today
BP
178 / 102
HR
88
SpO₂
97%
Wt
214 lb
Recent labs
A1c · 42d
8.4%
eGFR · 60d
52
UACR · 60d
118
LDL · 60d
94
Allergies
Sulfa · rash · documented 2019
NSAIDs · GI bleed · documented 2021
NSAIDs · GI bleed · documented 2021
Care team
Dr. Aliya Singh · PCP
Dr. Rosa Chen · Psychiatry
Dr. Daniel Greene · Cardio
Maria Reyes, RN · Care Coord
Dr. Rosa Chen · Psychiatry
Dr. Daniel Greene · Cardio
Maria Reyes, RN · Care Coord
SOAP note · auto-drafting
Dragon CoPilot · listening
Subjective edit
67-year-old male presenting for f/u of DM2 with poor control (A1c 8.4%) and recent BP elevation flagged via Doppler. Patient reports increased thirst, occasional blurred vision, and missed evening insulin doses 3-4×/week due to evening fatigue. Denies chest pain, shortness of breath, or focal weakness. PHQ-9 today: 14 (moderate); reports low mood since wife's hospitalization 6 weeks ago.
Live transcript view full
14:18:02
Dr. Singh: Jose, your home BP cuff has been showing some high numbers this week. Tell me how you've been feeling.
14:18:14
Patient: Honestly, doc, tired. Real tired. And the headaches are back, mostly in the morning.
14:18:32
Dr. Singh: Are you taking the lisinopril every morning?
14:18:38
Patient: Mostly. I forgot maybe twice last week.
14:19:04
Dr. Singh: And the evening insulin?
14:19:12
Patient: That one's harder. By the time dinner's over I'm wiped out and I just go to bed.
14:19:48
Dr. Singh: Let's talk about that. And how's your mood been? Last screener was a 14.
14:19:58
Patient: Since Maria went into the hospital it's been... heavy. I'm not sleeping right.
14:20:24
Dr. Singh: I want to get you back on track with your meds and check in on your mood more closely. Let me bring Maria Reyes in to set that up.
Objective add vitals
In-office BP 176/100; HR 88 reg; SpO₂ 97% RA. Weight 214 lb (+3 from last visit). General exam unremarkable. Foot exam: monofilament intact bilaterally, no ulcers. PHQ-9 administered, score 14; suicidal ideation absent (item 9 = 0).
Assessment & plan refine
1. DM2, uncontrolled (A1c 8.4%) — adherence barriers identified. Plan: switch evening insulin to morning long-acting; trial semaglutide 0.25 mg weekly pending eGFR re-check. Care coord to follow up adherence weekly.
2. HTN, stage 2 — uptitrate lisinopril 20 → 40 mg. Continue home BP monitoring (already enrolled). Cardio referral if > 160/100 sustained.
3. Depression w/ stressor — PHQ-9 14, situational. Engage BHI; refer to Dr. Chen for med reassessment. Care coord weekly check-in for 8 weeks.
4. CKD3 — eGFR 52. SGLT2i candidate after stabilization. Dietitian referral.
2. HTN, stage 2 — uptitrate lisinopril 20 → 40 mg. Continue home BP monitoring (already enrolled). Cardio referral if > 160/100 sustained.
3. Depression w/ stressor — PHQ-9 14, situational. Engage BHI; refer to Dr. Chen for med reassessment. Care coord weekly check-in for 8 weeks.
4. CKD3 — eGFR 52. SGLT2i candidate after stabilization. Dietitian referral.
Code suggestions · LCD-validated
99214
$112
Established pt · moderate complexity · 4 chronic conditions managed.
2 systems addressed · > 25 min
G2211
$16
Visit complexity add-on (longitudinal care).
established PCP relationship
96127
$5
PHQ-9 administered + scored.
documented score 14
99497
$78
Advance care planning · 30 min.
not yet documented · suggest
99484
$48
BHI care management · monthly.
already on track for May
Codes selected based on transcript + assessment + LCD policy for VA / Medicare. $133 captured · $259 max.
Orders · drafted
Lisinopril 40 mg PO daily
Up from 20 mg · #90 · 2 refills
Semaglutide 0.25 mg sq weekly
Pending eGFR re-check
Comprehensive metabolic panel
eGFR · K · Cr · BUN
A1c
3-month interval
Referral · Dr. Chen, Psych
Med reassessment, MDD
Referral · Dietitian
DM2 + CKD3 medical nutrition
Care plan · BHI 8-wk weekly
Maria Reyes coordinator
All orders require electronic signature before queue → send.
Visit type
99214 · est
moderate complexity
Time captured
14:32
qualifies for > 25 min
Codes accepted
3 of 5
2 still pending
Capture · this visit
$133
+$126 if all accepted
Doc completeness
94%
audit-ready