Patient presents with a history of squamous cell carcinoma (SCC).  Initial diagnosis of cutaneous squamous cell carcinoma occurred on [Date of original diagnosis] at [Location of original diagnosis - e.g., left forearm, lower lip].  The original lesion measured [Size of original lesion - e.g., 1.2 cm x 0.8 cm] and was described as [Description of original lesion - e.g., erythematous, ulcerated, indurated].  Histopathology confirmed the diagnosis of [Specific subtype if applicable - e.g., well-differentiated SCC, moderately differentiated SCC].  Treatment for the primary SCC consisted of [Treatment method - e.g., surgical excision with clear margins, Mohs micrographic surgery, radiation therapy].  Margins were reported as [Margin status - e.g., negative, positive].  Patient [Positive or negative nodal involvement at initial diagnosis].  Subsequent surveillance included [Follow-up regimen - e.g., physical exams every 3 months for the first year, then every 6 months for 5 years].  The patient reports no evidence of recurrence at the primary site.  Today's evaluation focuses on [Reason for current visit - e.g., routine skin cancer screening, evaluation of a new lesion].  Current physical exam reveals [Findings of current skin exam - e.g., a new 0.5 cm erythematous papule on the right cheek, no suspicious lesions identified].  Assessment includes history of squamous cell carcinoma, [Current status - e.g., no evidence of disease, suspected recurrence, new primary skin cancer].  Plan includes [Plan of care - e.g., biopsy of the new lesion, continued surveillance, referral to dermatology/oncology, patient education on sun protection].  ICD-10 code Z85.821 (personal history of malignant neoplasm of skin) is applicable.  Further coding may be necessary depending on the findings and plan.