Patient presents with right hand pain.  Onset of pain is described as (acute, subacute, chronic) and began (duration) ago.  The pain is located in the (dorsal, palmar, radial, ulnar) aspect of the hand and involves (specific digits, wrist, forearm).  Patient characterizes the pain as (sharp, dull, aching, throbbing, burning, radiating) and rates its severity as (0-10 pain scale).  Aggravating factors include (activities, movements, positions) while alleviating factors include (rest, ice, heat, medications).  Patient denies (or reports) any numbness, tingling, weakness, or swelling.  Past medical history includes (relevant conditions such as arthritis, carpal tunnel syndrome, prior injuries, diabetes).  Surgical history includes (any relevant hand or wrist surgeries).  Medications include (list current medications).  Allergies include (list allergies).  Social history includes (tobacco use, alcohol use, occupation, dominant hand).  Physical examination reveals (tenderness to palpation, range of motion limitations, deformity, edema, erythema, skin changes, neurological deficits, strength assessment).  Differential diagnosis includes (carpal tunnel syndrome, osteoarthritis, rheumatoid arthritis, tendinitis, De Quervain's tenosynovitis, trigger finger, ganglion cyst, fracture, sprain, strain).  Assessment: Right hand pain likely secondary to (presumptive diagnosis).  Plan:  (Conservative treatment such as rest, ice, compression, elevation, splinting, over-the-counter pain relievers, physical therapy referral, occupational therapy referral).  Consider (advanced imaging such as X-ray, MRI, ultrasound if indicated).  Follow-up in ( timeframe) to reassess symptoms and response to treatment.  Patient education provided regarding (activity modification, pain management techniques, potential complications).  ICD-10 code: (appropriate code based on diagnosis).