Patient presents with complaint of nausea and vomiting.  Onset, duration, frequency, and character of emesis were documented.  Associated symptoms such as abdominal pain, diarrhea, fever, chills, headache, dizziness, or lightheadedness were explored and recorded.  Precipitating factors including recent dietary intake, medication use, travel history, and possible exposures were investigated.  Severity of nausea and vomiting was assessed, noting any impact on hydration status and daily activities.  Pertinent negatives such as hematemesis, melena, or hematochezia were documented.  Physical examination findings including vital signs, abdominal exam, and neurological assessment were noted.  Differential diagnosis includes gastroenteritis, food poisoning, dehydration, pregnancy, migraine, medication side effects, gastroparesis, bowel obstruction, appendicitis, and other gastrointestinal disorders.  Assessment includes evaluation for dehydration based on clinical signs and symptoms.  Laboratory studies may include a complete blood count, basic metabolic panel, urinalysis, pregnancy test if applicable, and stool studies if indicated.  Treatment plan includes antiemetics such as ondansetron or promethazine, intravenous fluids if necessary for rehydration, dietary modifications as tolerated, and patient education regarding oral rehydration solutions.  Follow-up care was discussed and scheduled as needed.  Medical coding will consider ICD-10-CM codes for nausea and vomiting (R11.0, R11.1, R11.2) along with any associated diagnoses, and CPT codes for evaluation and management services as well as any procedures performed.  This documentation supports medical necessity for services rendered and facilitates accurate billing and reimbursement.