Office Visit Note
Narrative: CHIEF COMPLAINT Mother requesting Tdap vaccine for Micah before he leaves for college; patient not present today HISTORY OF PRESENT ILLNESS Micah is a patient whose mother presented today (without the patient) to discuss vaccine needs prior to college departure. Mother reports Micah needs a Tdap vaccine before attending Grand Canyon University (GCU) in Phoenix. She notes he is behind on vaccines. Micah was not present at today's visit. He is expected to leave for college around September 1st. Mother will need to coordinate with Micah regarding his schedule to arrange a visit for vaccination. ASSESSMENT 1. Vaccine update needed prior to college - Tdap identified as priority vaccine; patient not present today for administration PLAN 1. Tdap vaccine needed before college departure in September. Mother will coordinate with Micah's schedule to bring him in for a visit to receive the Tdap and address any other outstanding vaccine needs prior to his departure for GCU. FOLLOW-UP Schedule visit for Micah prior to September 1st college departure for Tdap administration. ICD-10 CODES Z23 - Encounter for immunization CPT CODES 99211 - Office visit, established patient, minimal complexity (no patient present, nurse/staff-level coordination) ───────────────────────────────────────── CODES: CPT 99211 | ICD-10 Z23 Source: Cloud iOS recording (2026-07-23T19:58), backfilled from device 2026-08-23