Patient presents with hoarseness, also described as dysphonia or a raspy voice.  Onset of symptoms was [duration] and is characterized by [quality of hoarseness; e.g., rough, breathy, strained, weak].  Associated symptoms include [list associated symptoms; e.g., throat clearing, cough, dysphagia, odynophagia, shortness of breath, globus sensation, reflux symptoms, neck pain].  Patient reports [aggravating factors; e.g., voice overuse, allergies, upper respiratory infection] and [alleviating factors; e.g., voice rest, hydration].  Patient denies [pertinent negatives; e.g., hemoptysis, weight loss, dyspnea at rest].  Social history includes [smoking status, alcohol use, occupational voice use].  Medications include [list current medications].  Allergies include [list allergies].  Physical examination reveals [laryngeal appearance; e.g., erythematous, edematous vocal cords; presence of lesions, vocal fold mobility].  Differential diagnosis includes acute laryngitis, vocal cord nodules, vocal cord polyps, Reinke's edema, laryngopharyngeal reflux, muscle tension dysphonia, and, less commonly, laryngeal cancer.  Assessment includes hoarseness, likely secondary to [presumptive diagnosis].  Plan includes [treatment plan; e.g., voice rest, hydration, voice therapy referral, medication for reflux, ENT referral for further evaluation if symptoms persist beyond [timeframe], consideration for laryngoscopy].  ICD-10 code [appropriate ICD-10 code, e.g., R49.0] is considered.  Patient education provided regarding voice hygiene and follow-up care.