Patient presents with skin changes.  Detailed examination reveals [specific morphology, e.g., macules, papules, plaques, vesicles, bullae, nodules, tumors, pustules, erosions, ulcers, crusts, scales, atrophy, lichenification, or a combination thereof].  The [color, e.g., erythematous, violaceous, hypopigmented, hyperpigmented] lesions are located on the [body location, e.g., face, trunk, extremities, specific anatomical site].  Lesions are [size in millimeters or centimeters] and [shape, e.g., round, oval, irregular].  The [texture, e.g., smooth, rough, verrucous] of the skin changes is noted.  Patient reports [associated symptoms, e.g., pruritus, pain, burning, tingling, numbness].  Onset of skin changes was [timeframe].  Patient denies [relevant negatives, e.g., fever, chills, weight loss, recent travel].  Medical history includes [relevant medical history, e.g., atopic dermatitis, psoriasis, eczema, allergies].  Current medications include [list medications].  Family history is significant for [relevant family history, e.g., skin cancer, psoriasis].  Differential diagnosis includes [list of potential diagnoses, e.g., contact dermatitis, eczema, psoriasis, tinea, drug eruption].  Assessment:  Skin changes consistent with [likely diagnosis].  Plan:  [Treatment plan including topical medications, systemic medications, or referrals, e.g., Prescribed hydrocortisone cream 1 twice daily to affected area.  Patient education provided on trigger avoidance and proper skin care.  Follow-up scheduled in two weeks to assess response to treatment. Referral to dermatology if no improvement].  ICD-10 code:  [appropriate ICD-10 code based on diagnosis].