Patient presents with right finger pain.  Onset of pain is described as (acute, subacute, chronic) and began (duration) ago.  Location of pain is specified as (finger number, distal, proximal, medial, lateral) and patient identifies the pain as (sharp, dull, throbbing, aching, radiating).  The patient reports (aggravating factors such as movement, pressure, rest) and (alleviating factors such as ice, heat, rest, elevation).  Patient denies (or reports) any associated symptoms including numbness, tingling, swelling, redness, warmth, or limited range of motion.  Past medical history includes (relevant medical conditions such as arthritis, diabetes, prior injury) and surgical history is (positive or negative for finger surgery).  Medications include (list current medications).  Allergies include (list allergies).  Physical examination reveals (tenderness to palpation, swelling, erythema, deformity, range of motion limitations).  Differential diagnosis includes (sprain, strain, fracture, tendonitis, arthritis, tenosynovitis, trigger finger).  Assessment is right finger pain, likely due to (presumed diagnosis).  Plan includes (conservative management with RICE protocol - rest, ice, compression, elevation, pain medication such as NSAIDs, splinting, referral to hand specialist if needed, further imaging such as x-ray if clinically indicated).  Patient education provided regarding activity modification, pain management, and follow-up care.  Follow-up scheduled in (duration).  Return precautions discussed with the patient, including worsening pain, numbness, tingling, or signs of infection.  ICD-10 code (appropriate code based on presumed diagnosis), CPT code (appropriate code based on evaluation and management services provided) for medical billing and coding.