Patient presents with left hand pain.  Onset of pain is described as (acute, subacute, chronic), occurring (duration) ago.  The pain is characterized as (sharp, dull, aching, throbbing, burning, radiating, electric) and located in the (dorsal, palmar, radial, ulnar) aspect of the hand, involving the (digits, wrist, forearm).  Patient reports (aggravating factors such as movement, rest, specific activities) and (alleviating factors such as rest, ice, heat, medication).  Associated symptoms include (numbness, tingling, weakness, swelling, stiffness, redness, warmth).  Patient denies (pertinent negatives such as fever, trauma, rash).  Medical history includes (relevant medical history such as diabetes, arthritis, carpal tunnel syndrome, prior hand injuries).  Medications include (list current medications).  Allergies include (list allergies).  Physical examination reveals (tenderness, swelling, deformity, limited range of motion, decreased grip strength, sensory changes, positive Phalen's test, positive Tinel's sign).  Differential diagnosis includes carpal tunnel syndrome, arthritis, tendinitis, tenosynovitis, nerve entrapment, fracture, sprain, strain.  Assessment: Left hand pain, likely due to (presumptive diagnosis).  Plan: (Ordered diagnostic tests such as X-ray, MRI, nerve conduction studies).  Treatment plan includes (conservative management such as rest, ice, compression, elevation, splinting, physical therapy, occupational therapy, medication such as NSAIDs, analgesics, corticosteroids) andor (referral to specialist such as orthopedist, hand surgeon, neurologist).  Patient education provided regarding (activity modification, pain management strategies).  Follow-up scheduled in (timeframe) to reassess symptoms and response to treatment.  ICD-10 code: (appropriate ICD-10 code based on presumptive diagnosis).