Patient presents for pregnancy screening.  Reason for encounter includes possible pregnancy, missed menses, or desire to confirm pregnancy status.  Patient reports last menstrual period (LMP) on [Date], with a cycle length of [Number] days.  Gravidity is [Number] and parity is [Number].  Patient's current symptoms include [List symptoms e.g., nausea, fatigue, breast tenderness, or none].  Relevant medical history includes [List relevant medical history e.g., prior pregnancies, gestational diabetes, preeclampsia, or none].  Medications include [List current medications]. Allergies include [List allergies].  Physical examination reveals [Document vital signs and relevant physical findings e.g., uterus size consistent with dates, or no abnormalities noted].  Differential diagnosis includes early pregnancy, ectopic pregnancy, and other causes of amenorrhea.  Plan includes urine human chorionic gonadotropin (hCG) test performed in office.  Results are [Positive or Negative].  If positive,  estimated gestational age (EGA) based on LMP is [Number] weeks.  Patient counseling provided regarding pregnancy confirmation, prenatal care options, and available resources.  Follow-up scheduled for [Date] for [Reason e.g., obstetric ultrasound, prenatal appointment].  Diagnosis: Pregnancy screening.  ICD-10 code: Z32.01 (Encounter for pregnancy test). CPT code [Applicable CPT code depending on the service provided, e.g., 81025 for urine pregnancy test].