Patient presents with a history of cerebrovascular accident (CVA), consistent with a past stroke.  Onset of initial stroke symptoms occurred on [Date of Onset].  The patient reports [Specific symptoms experienced during the initial stroke event e.g., right-sided weakness, aphasia, dysphagia, visual field deficits].  The type of stroke was determined to be [Ischemic, Hemorrhagic, or unspecified] based on [Diagnostic method used e.g., MRI, CT scan, clinical presentation].  Current residual deficits include [List current symptoms and their severity e.g., mild right-sided hemiparesis, expressive aphasia].  The patient's current functional status is [Describe functional level e.g., independent in activities of daily living, requires assistance with ambulation].  Medications related to stroke management include [List medications, dosages, and frequencies e.g., Aspirin 81mg daily, Atorvastatin 40mg daily].  Blood pressure is currently well-controlled at [Systolic/Diastolic reading].  Neurological examination reveals [Current neurological findings].  Risk factors for stroke include [List relevant risk factors e.g., hypertension, hyperlipidemia, diabetes mellitus, atrial fibrillation, smoking history].  Patient is advised to continue current medications and follow up with neurology for ongoing management of stroke sequelae.  Recommendations provided for [Lifestyle modifications, therapy services e.g., physical therapy, occupational therapy, speech therapy]. This documentation supports ICD-10 code I69.4 (Sequelae of cerebrovascular disease) and reflects ongoing chronic care management for history of stroke. Future assessments will focus on monitoring for recurrent stroke, optimizing functional recovery, and managing vascular risk factors.