Patient presents with a chief complaint of hoarseness, dysphonia, or voice changes.  Onset of symptoms was (duration) and is described as (character of hoarseness: e.g., rough, breathy, strained, weak, etc.).  Associated symptoms may include throat clearing, cough, vocal fatigue, dysphagia, odynophonia, globus sensation, or shortness of breath.  Patient reports (presence or absence) of recent upper respiratory infection, allergies, vocal overuse, laryngopharyngeal reflux, smoking, alcohol use, or exposure to environmental irritants.  Past medical history includes (relevant medical conditions e.g., thyroid disorders, neurological conditions, prior neck surgery or trauma).  Medications include (list current medications).  Family history is (positive or negative) for voice disorders or head and neck cancers.  Physical examination reveals (describe findings including laryngeal appearance on indirect or flexible laryngoscopy if performed: e.g., vocal fold mobility, erythema, edema, lesions).  Differential diagnosis includes vocal fold nodules, polyps, cysts, laryngitis, Reinke's edema, vocal cord paralysis, laryngeal cancer, muscle tension dysphonia, and neurological voice disorders.  Assessment:  Hoarse voice likely secondary to (presumed etiology).  Plan includes (recommendations for treatment e.g., voice therapy, medication for reflux, further investigation with laryngeal imaging or ENT specialist referral if indicated).  Patient education provided regarding vocal hygiene, including hydration, voice rest, and avoidance of irritants. Follow-up scheduled for (date/time) to reassess voice quality and treatment response. ICD-10 code R49.0 (Dysphonia) may be considered pending definitive diagnosis.  CPT codes for evaluation and management (e.g., 99202-99205 or 99211-99215) and any procedures performed (e.g., flexible laryngoscopy) will be documented separately based on complexity.