Patient presents with a left below-knee amputation (BKA), status post surgical amputation performed on [Date of amputation].  The amputation level is transtibial.  The patient reports [phantom limb pain/no phantom limb pain] and the residual limb appears [well-healed/exhibiting signs of  [Specify: e.g., dehiscence, infection, skin breakdown]].  Current dressings are [Describe dressing type and condition].  Assessment of the residual limb reveals [Describe: e.g., good tissue perfusion, palpable pulses, presence or absence of edema, skin temperature].  Patient's gait was assessed with [Assistive device used, if any. e.g., prosthetic, crutches, walker]. Gait analysis reveals [Describe gait characteristics, e.g., stable, unsteady, antalgic].  Pain level reported as [Pain scale used and rating, e.g.,  0-10 scale, 4/10].  Patient is currently receiving [physical therapy/occupational therapy/no therapy] focused on [Therapy goals, e.g., prosthetic training, strengthening, range of motion, pain management, activities of daily living].  Prosthetic fitting is [planned/in progress/completed].  Patient education provided regarding residual limb care, pain management, and fall prevention.  Follow-up appointment scheduled for [Date of next appointment] to monitor healing, address any complications, and continue rehabilitation plan.  ICD-10 code Z89.414 (Acquired absence of left leg below knee) is applicable.  Discussions regarding long-term prosthetic options, ongoing pain management strategies, and psychosocial support are ongoing.