Patient presents with a history of renal cell carcinoma (RCC), diagnosed on [Date of Diagnosis].  The primary tumor was located in the [Location: e.g., upper pole of the left kidney] and was classified as stage [Stage: e.g., T1aN0M0] according to the TNM staging system.  Histological subtype was determined to be [Histological Subtype: e.g., clear cell RCC].  Initial treatment consisted of [Treatment: e.g., radical nephrectomy] performed on [Date of Surgery].  Surgical pathology confirmed the diagnosis and margins were reported as [Margin Status: e.g., negative].  Postoperative imaging surveillance with [Imaging Modality: e.g., CT abdomen and pelvis] has been performed at [Frequency: e.g., 6-month intervals].  The most recent scan on [Date of Last Scan] showed [Findings: e.g., no evidence of recurrent disease].  Patient reports [Current Symptoms: e.g., no current symptoms related to RCC].  Physical examination is unremarkable for lymphadenopathy or palpable abdominal masses.  Assessment: History of renal cell carcinoma, status post [Treatment], currently under surveillance.  Plan: Continue surveillance imaging per established protocol.  Patient education provided regarding signs and symptoms of recurrence, including hematuria, flank pain, and weight loss.  Discussed importance of follow-up appointments and adherence to the surveillance schedule.  Patient understands and agrees with the plan.  ICD-10 code C64 (malignant neoplasm of kidney, except renal pelvis) is applicable, along with appropriate procedure codes for the specific treatment provided and surveillance imaging.