Patient presents with sequelae of (specify original condition, e.g., cerebrovascular accident, traumatic brain injury, myocardial infarction).  The current presenting symptoms include (document specific symptoms, e.g., residual hemiparesis, cognitive impairment, dysphagia, chronic pain).  These symptoms are consistent with the documented history of (original condition) and represent a chronic, persistent condition resulting from the prior event.  Onset of the original condition was (date of original condition).  Current functional limitations include (list limitations, e.g., difficulty with activities of daily living, limitations in mobility, impaired communication).  Assessment includes review of prior medical records, physical examination, and (list any additional diagnostic tests performed, e.g., neurocognitive testing, imaging studies).  Diagnosis of sequelae of (original condition) is confirmed based on the patient's history, current symptoms, and functional limitations.  The patient's condition is stable, but chronic.  Plan of care includes (describe treatment plan, e.g., physical therapy, occupational therapy, speech therapy, pain management, medication management).  Patient education provided regarding management of sequelae, including strategies for symptom control and maximizing functional independence.  Follow-up scheduled in (duration) to monitor progress and adjust treatment plan as needed.  ICD-10 code (appropriate code for the specific sequela) is applied for medical billing and coding purposes.  Prognosis for significant improvement is (state prognosis, e.g., guarded, fair, good) based on the chronicity of the condition.  Continued supportive care and symptom management are recommended.