Patient presents with post-operative pain following [Surgical Procedure Name] performed on [Date of Surgery].  Pain assessment reveals [Pain Location - e.g., incisional, abdominal, generalized] pain characterized as [Pain Quality - e.g., sharp, dull, aching, throbbing, burning] with a severity of [Pain Scale Rating - e.g.,  NRS 7/10, Wong-Baker Faces scale indicating moderate pain].  Patient reports the pain is [Pain Timing - e.g., constant, intermittent, worse with movement, relieved by rest] and impacting [Activities of Daily Living - e.g., ambulation, sleep, deep breathing].  Surgical site appears [Wound Assessment - e.g., well-approximated, clean, dry, no signs of infection, erythema present, drainage noted].  Review of systems pertinent to post-surgical complications is negative for fever, chills, excessive bleeding, or signs of deep vein thrombosis.  Current medications include [List current medications including pain medications, dosage, and frequency].  Diagnosis: Post-operative pain.  Plan:  Continue current pain management regimen.  Educate patient on pain control strategies including splinting, deep breathing exercises, and activity modification.  Monitor pain levels and adjust analgesics as needed.  Follow-up appointment scheduled for [Date of Follow-up].  Differential diagnoses considered included surgical site infection, hematoma, and nerve irritation.  ICD-10 code: [Appropriate ICD-10 code - e.g., G89.18 - Other chronic postprocedural pain].