Patient presents with concerns regarding possible sexually transmitted infection (STI).  Chief complaint includes [insert specific chief complaint, e.g., dysuria, genital discharge, pelvic pain, penile discharge, or asymptomatic presentation for screening].  Review of systems reveals [document pertinent positives and negatives related to STIs, including genitourinary symptoms, constitutional symptoms like fever or fatigue, dermatological manifestations, and any relevant past medical history of STIs].  Sexual history obtained includes number of partners, type of sexual activity, condom use, and history of prior STIs.  Physical examination reveals [document relevant findings, including description of any lesions, discharge characteristics, and findings from pelvic or genital examination].  Differential diagnosis includes chlamydia, gonorrhea, syphilis, herpes simplex virus (HSV), human papillomavirus (HPV), trichomoniasis, and other STIs.  Based on clinical presentation and risk factors, the following diagnostic tests were ordered: [list tests ordered, e.g., nucleic acid amplification test (NAAT) for chlamydia and gonorrhea, syphilis serology (RPR, VDRL), HSV PCR, HPV testing if indicated, wet mount microscopy for trichomoniasis].  Patient education provided regarding safer sex practices, partner notification, and the importance of treatment adherence.  Pending test results, presumptive treatment for [specific STI if applicable] initiated with [medication name, dosage, and route of administration].  Follow-up appointment scheduled to review test results and discuss further management.  ICD-10 code(s) [insert relevant ICD-10 codes] and CPT code(s) [insert relevant CPT codes for evaluation and management, procedures, and laboratory tests] will be assigned based on final diagnosis and treatment provided.  Medical necessity for testing and treatment documented.