Patient presents with a personal history of cerebrovascular accident (CVA), commonly referred to as a stroke.  The initial stroke event occurred on [Date of Stroke], documented as [Type of Stroke - ischemic, hemorrhagic, or unspecified] affecting the [Location of Stroke - e.g., left middle cerebral artery territory].  The patient reports [Residual Symptoms - e.g., right-sided hemiparesis, aphasia, dysphagia] which are [Severity of Residual Symptoms - e.g., mild, moderate, severe] in nature.  Current medications include [Medications Related to Stroke - e.g., aspirin, clopidogrel, statin, antihypertensive medications] for secondary stroke prevention.  Risk factors for stroke identified include [Stroke Risk Factors - e.g., hypertension, hyperlipidemia, atrial fibrillation, diabetes mellitus, smoking history].  Neurological examination reveals [Current Neurological Findings - e.g., intact cranial nerves, decreased strength in right upper and lower extremities, sensory deficits].  The patient is advised to continue with the prescribed medication regimen and lifestyle modifications, including [Lifestyle Modifications - e.g., diet, exercise, smoking cessation].  Follow-up with neurology is scheduled for [Date of Follow-up] to monitor for any new neurological deficits and assess the effectiveness of the current treatment plan.  ICD-10 code I63.9 Personal history of stroke, not specified as haemorrhagic or ischaemic is assigned.  This documentation supports medical necessity for ongoing stroke management and secondary prevention strategies.