Patient presents with a hematoma, characterized by a localized collection of blood outside the blood vessels.  Onset of symptoms occurred [timeframe] following [mechanism of injury, e.g., trauma, surgery, spontaneous].  Location of the hematoma is documented as [anatomical location, e.g., subdural, intramuscular, subcutaneous].  Size of the hematoma is approximately [measurement] in diameter.  Associated symptoms include [list symptoms, e.g., pain, swelling, bruising, tenderness, limited range of motion].  Skin overlying the hematoma appears [description, e.g., ecchymotic, erythematous, intact].  Palpation reveals [description, e.g., fluctuance, induration, tenderness].  Differential diagnosis includes [list potential alternative diagnoses, e.g., abscess, tumor, cyst].  Diagnosis of hematoma is supported by [diagnostic methods, e.g., physical examination, imaging studies].  Treatment plan includes [treatment options, e.g., observation, ice, compression, elevation, pain management, surgical intervention].  Patient education provided on [topics, e.g., signs of infection, pain management strategies, follow-up care].  Follow-up appointment scheduled for [date] to monitor hematoma resolution and assess for any complications, such as infection or nerve compression.  ICD-10 code [relevant ICD-10 code] is assigned.  CPT codes for procedures performed are documented.