Patient presents with a history of mastectomy.  The patient reports a previous surgical removal of breast tissue due to breast cancer.  Documentation of the specific type of mastectomy performed is crucial for accurate medical coding and billing, including whether it was a unilateral or bilateral mastectomy, and whether it involved a simple mastectomy, modified radical mastectomy, radical mastectomy, skin-sparing mastectomy, or nipple-sparing mastectomy.  The date of the mastectomy procedure, the surgeon's name, and the facility where the surgery took place should be documented.  Information regarding any reconstructive surgery following the mastectomy, such as breast reconstruction with implants or autologous tissue, should also be recorded.  Relevant past medical history includes the specific type of breast cancer diagnosis (e.g., ductal carcinoma in situ, invasive ductal carcinoma, lobular carcinoma in situ, invasive lobular carcinoma), stage of cancer at diagnosis, and any neoadjuvant or adjuvant therapies received, such as chemotherapy, radiation therapy, hormonal therapy, or targeted therapy.  Current symptoms, such as pain, lymphedema, or range of motion limitations, should be assessed and documented.  Physical examination findings relevant to the mastectomy site, including scar assessment, presence of seroma or hematoma, and assessment of lymph nodes, should be thoroughly documented.  Ongoing surveillance and follow-up care plans, including recommendations for mammograms, breast MRI, or other imaging studies, should be clearly outlined.  This comprehensive documentation supports accurate clinical care, medical billing, and coding for patients with a history of mastectomy.