Patient presents with a right lower leg wound.  Location of the wound is documented, specifying anatomical landmarks such as anterior, posterior, lateral, or medial aspect of the lower leg.  Detailed wound assessment includes size in centimeters,  depth, shape (circular, irregular, linear), wound bed characteristics (granulating tissue, slough, eschar),  exudate description (serous, sanguinous, purulent, amount), and surrounding skin condition (erythema, edema, induration, maceration).  Assessment for signs of infection, including cellulitis, abscess, or osteomyelitis, is documented.  Patient's pain level is assessed and documented using a validated pain scale.  The etiology of the wound is explored, including traumatic injury, venous insufficiency, arterial ulcer, diabetic ulcer, pressure injury, or other underlying medical conditions.  Relevant medical history, including diabetes, peripheral vascular disease,  immunosuppression, and previous wound treatments, is noted.  Current medications, allergies, and tetanus immunization status are documented.  Treatment plan includes wound care management, such as debridement (if necessary), dressing type (alginate, foam, hydrogel), compression therapy (if appropriate), and frequency of dressing changes.  Patient education provided regarding wound care instructions, signs of infection, and follow-up appointments.  Differential diagnoses considered and rationale for chosen diagnosis provided.  ICD-10 code assigned based on etiology and characteristics of the wound (e.g., L97.411  Non-pressure chronic ulcer of right lower leg with unspecified severity).  CPT codes for procedures performed, such as debridement or wound closure, are documented.  Plan for future wound assessments and adjustments to the treatment plan as needed.