Patient presents with a keloid scar, a raised, overgrown scar tissue formation, at the site of previous [specify type of injury or procedure, e.g., surgical incision, trauma, acne lesion, ear piercing, burn].  The keloid extends beyond the original wound boundary, exhibiting [describe color, e.g., pink, red, purple, brown] coloration and a firm, rubbery, or nodular texture.  Patient reports [describe symptoms: e.g., pruritus, pain, tenderness, burning sensation, cosmetic concerns].  The keloid measures [dimensions in length x width x height] cm.  No signs of infection or drainage are noted.  Differential diagnoses considered include hypertrophic scar, dermatofibroma, and granuloma annulare.  Based on clinical presentation and patient history, the diagnosis of keloid is confirmed.  Treatment plan discussed includes [specify treatment options: e.g., intralesional corticosteroid injection, silicone gel sheeting, pressure therapy, cryotherapy, laser therapy, surgical excision, radiation therapy] with patient education on potential benefits, risks, and expected outcomes.  Follow-up appointment scheduled in [duration] for reassessment and treatment adjustment as needed.  ICD-10 code L91.0 Keloid scar is assigned.  Procedure codes for treatment will be assigned upon completion of the procedure.  Patient understands and agrees with the proposed treatment plan.