Patient presents with a history of alcohol use, characterized by [frequency and quantity of alcohol consumption, e.g., daily consumption of six beers].  The patient reports [onset of alcohol use, e.g., beginning at age 18] and describes [pattern of alcohol use, e.g., periods of heavy drinking followed by attempts at abstinence].  Symptoms related to alcohol use include [list specific symptoms, e.g., insomnia, anxiety, irritability, tremors].  The patient [denies/admits] experiencing alcohol withdrawal symptoms such as [list specific withdrawal symptoms, e.g., seizures, hallucinations, delirium tremens].  Family history is [positive/negative] for alcohol use disorder.  Social history indicates [patient's social support system, living situation, and occupational status].  Mental status examination reveals [patient's mental state, e.g., alert and oriented, anxious, depressed].  Assessment suggests a diagnosis of [specify diagnosis, e.g., Alcohol Use Disorder, mild, moderate, or severe,  or Alcohol Dependence] based on DSM-5 criteria.  Differential diagnoses considered include [list relevant differential diagnoses, e.g., Generalized Anxiety Disorder, Major Depressive Disorder].  The patient's current medication list includes [list medications].  The treatment plan includes [specific interventions, e.g., brief intervention, referral to substance abuse counseling, medication-assisted treatment, support groups].  Patient education provided regarding the risks of alcohol use and the benefits of treatment.  Follow-up appointment scheduled for [date] to monitor progress and adjust treatment as needed.  ICD-10 code [relevant ICD-10 code, e.g., F10.10 for Alcohol Dependence] is assigned.