Patient presents with a left foot ulcer.  Location of the ulcer is documented as (specify anatomical location, e.g., plantar surface of the great toe, medial malleolus, etc.).  Ulcer dimensions are measured as length x width x depth in centimeters and documented.  Ulcer characteristics include (describe appearance, e.g., granulating, necrotic, fibrinous, hypergranulating) with (describe exudate, e.g., serous, serosanguinous, purulent, amount).  Surrounding skin is assessed for signs of infection (erythema, edema, warmth, induration) and described (e.g., intact, macerated, calloused).  Peripheral pulses (dorsalis pedis, posterior tibial) are palpated and documented as palpable or non-palpable.  Neuropathy assessment includes monofilament testing and vibration sense, results documented.  Patient reports pain level of (scale 0-10) associated with the ulcer.  Etiology of the ulcer is suspected to be (e.g., diabetic foot ulcer, venous stasis ulcer, arterial ulcer, pressure ulcer) based on clinical presentation and patient history.  Assessment includes evaluation for peripheral artery disease, venous insufficiency, and diabetes mellitus.  Differential diagnosis includes infection, cellulitis, osteomyelitis, deep vein thrombosis.  Plan includes (specify wound care regimen, e.g., debridement, dressings, offloading) and further investigations as needed (e.g., vascular studies, wound cultures, X-ray).  Patient education provided on wound care, foot care, and risk factor modification.  Follow-up appointment scheduled for (date) to monitor ulcer healing and adjust treatment plan as indicated.  ICD-10 code (specify appropriate code, e.g., L97.419 for non-pressure chronic ulcer of left heel and midfoot) and CPT codes for wound care procedures will be documented based on services rendered.