Patient presents with a pressure ulcer on the buttock.  Assessment reveals a stage [Insert Stage: I, II, III, IV, Unstageable, Deep Tissue Pressure Injury] pressure injury located on the [Right/Left] buttock over the [Specific anatomical location, e.g., ischial tuberosity, gluteal cleft, sacrum if adjacent].  The wound measures [Length] x [Width] x [Depth] cm.  Wound bed appears [Describe appearance, e.g., erythematous, granulating, necrotic, sloughy].  The surrounding skin is [Describe surrounding skin, e.g., intact, macerated, indurated, with or without erythema].  Patient reports [Pain level and description, e.g., no pain, mild tenderness, moderate aching, severe throbbing].  Pain assessment using a [Pain Scale used, e.g., numerical rating scale] reveals a pain score of [Pain Score].  Contributing factors include [List contributing factors, e.g., immobility, moisture, shear, friction, malnutrition].  The patient's current mobility status is [Describe mobility, e.g., bedbound, chairfast, transfers with assistance, ambulates independently].  Nutritional status assessment indicates [Describe nutritional status, e.g., adequate intake, at risk for malnutrition, requires nutritional supplementation].  Plan of care includes [List treatment plan, e.g., pressure redistribution using [Specific device, e.g., alternating pressure mattress, foam cushion], wound care with [Specific dressing type, e.g., saline moistened gauze, hydrocolloid, alginate], debridement [If applicable, specify type, e.g., sharp, enzymatic, autolytic], pain management with [Specify pain management strategy, e.g., analgesics, topical anesthetics], nutritional support with [Specify nutritional interventions, e.g., high-protein diet, protein supplements], and frequent repositioning every [Frequency, e.g., two hours]].  Patient education provided regarding pressure ulcer prevention, including proper skin care, turning and positioning techniques, and importance of nutrition.  ICD-10 code [Insert appropriate ICD-10 code, e.g., L89.159, L89.312] assigned.  Referral to [Specialists involved, e.g., wound care nurse, dietitian, physical therapist] made. Follow-up scheduled in [Duration, e.g., one week].