Patient presents with complaints consistent with sleep disturbance, including difficulty falling asleep, frequent awakenings during the night, early morning awakening, and non-restorative sleep.  Symptoms impact daytime functioning, causing fatigue, difficulty concentrating, irritability, and daytime sleepiness.  Patient reports these sleep problems have been ongoing for approximately [duration], with a gradual or sudden onset as described by the patient.  Review of systems reveals [positive/negative] for symptoms suggestive of obstructive sleep apnea, restless legs syndrome, periodic limb movement disorder, narcolepsy, or other sleep-wake disorders.  Patient denies use of sleep medications, alcohol, or caffeine before bed.  Medical history is significant for [relevant medical comorbidities, e.g., anxiety, depression, chronic pain] and current medications include [list current medications].  Physical examination findings are within normal limits.  Assessment: Sleep disturbance, likely related to [provisional diagnosis, e.g., insomnia, stress, medical comorbidity].  Plan:  Patient education on sleep hygiene practices, including regular sleep schedule, creating a relaxing bedtime routine, and avoiding caffeine and alcohol before bed.  Consider referral to sleep specialist for further evaluation, including polysomnography if clinically indicated.  Initiate [behavioral therapy, e.g., Cognitive Behavioral Therapy for Insomnia or CBT-I] or pharmacologic intervention if indicated and appropriate. Follow-up scheduled in [timeframe] to assess response to treatment and adjust plan as needed.  Differential diagnoses include insomnia disorder, hypersomnolence disorder, circadian rhythm sleep-wake disorders, parasomnias, and sleep disorders related to other medical conditions or substance use.  ICD-10 code considerations include [relevant ICD-10 codes, e.g., G47.00, G47.01, F51.01, G47.10].