Patient presents for evaluation of prolonged prothrombin time (PT).  Chief complaint includes [insert patient's chief complaint related to prolonged PT, e.g., easy bruising, bleeding gums, etc.].  Review of systems reveals [document pertinent positives and negatives related to bleeding and clotting disorders, e.g., history of epistaxis, hematuria, recent surgery, family history of bleeding disorders, medications such as anticoagulants, NSAIDs, or herbal supplements].  Physical examination reveals [document relevant physical findings, e.g., presence of petechiae, purpura, ecchymosis, active bleeding].  Current medications include [list all current medications including dosage and frequency].  Patient's INR is [insert INR value].  Differential diagnosis includes vitamin K deficiency, liver disease, disseminated intravascular coagulation (DIC), factor deficiency (e.g., Factor VII deficiency), and effects of anticoagulant therapy (e.g., warfarin).  Based on the patient's presentation, history, and laboratory findings, the assessment is prolonged prothrombin time likely secondary to [state most likely cause based on clinical findings].  Plan includes [outline plan for further investigation and management, e.g., repeat PT/INR, liver function tests, vitamin K administration, adjustment of anticoagulant therapy, referral to hematologist if indicated].  Patient education provided regarding the importance of medication adherence, dietary considerations if relevant, and signs and symptoms of bleeding complications.  Follow-up scheduled for [date] to re-evaluate PT/INR and assess response to treatment.  ICD-10 code: [insert appropriate ICD-10 code, e.g., D68.30 for unspecified coagulation defect or other appropriate code based on etiology].