Patient presents with a history of substance use disorder, consistent with a diagnosis of history of drug abuse (F19.20).  The patient reports past problematic use of [Specific drug or drug class, e.g., opioids, stimulants, cannabis], meeting criteria for dependence as evidenced by [Specific DSM-5 criteria, e.g., tolerance, withdrawal, continued use despite negative consequences].  Onset of use was reported at age [age].  The patient describes [Frequency, duration, and route of administration, e.g., daily intravenous heroin use for five years].  The patient reports [Specific consequences of drug abuse, e.g., legal problems, relationship difficulties, job loss, overdose history].  Past treatment history includes [Details of prior treatment episodes, e.g., inpatient detoxification, residential rehabilitation, outpatient counseling, medication-assisted treatment].  Current symptoms related to past drug abuse include [Current symptoms, e.g., cravings, anxiety, insomnia].  Physical examination reveals [Relevant physical findings, e.g., track marks, evidence of malnutrition, abnormal liver function tests].  Assessment includes consideration of co-occurring mental health disorders, such as [Differential diagnoses, e.g., depression, anxiety, PTSD].  The patient is motivated for [Level of motivation for treatment, e.g., abstinence, harm reduction].  The treatment plan includes [Specific interventions, e.g., referral to addiction specialist, individual therapy, support groups, pharmacotherapy options like naltrexone or buprenorphine].  Patient education provided regarding relapse prevention strategies and community resources.  Prognosis is guarded given the chronic nature of addiction.  Follow-up scheduled in [Timeframe, e.g., one week] to monitor progress and adjust treatment as needed.  ICD-10 code F19.20 and relevant CPT codes for evaluation and management will be documented for billing purposes.