Patient presents status post craniotomy performed on [Date of Procedure] for [Reason for Craniotomy, e.g., resection of meningioma, evacuation of subdural hematoma, clipping of aneurysm].  The craniotomy site is [Location of Craniotomy, e.g., right frontal, left parietal] and appears [Description of Craniotomy Site, e.g., well-healed, with staples intact, with signs of early healing].  Neurological examination reveals [Neurological Findings, e.g., intact cranial nerves, mild left-sided weakness, no aphasia].  Patient's mental status is [Mental Status Description, e.g., alert and oriented to person, place, and time, mildly confused].  Post-operative pain is managed with [Pain Management Regimen, e.g., acetaminophen, ibuprofen, oxycodone as needed].  The patient is tolerating a [Diet Description, e.g., regular diet, clear liquid diet].  Wound care instructions were reviewed with the patient and caregiver.  Signs and symptoms of intracranial complications, such as infection, cerebrospinal fluid leak, and increased intracranial pressure, were reviewed.  Current medications include [List of Medications].  Plan includes continued neurological monitoring, wound care, and pain management.  Follow-up appointment scheduled for [Date of Follow-up] with [Name of Provider].  ICD-10 code [Appropriate ICD-10 Code, e.g., Z90.898, other postprocedural status] is considered.  Differential diagnoses considered included [Relevant Differential Diagnoses, if applicable].  The patient's prognosis is [Prognosis Description, e.g., good, fair, guarded]. This documentation supports medical necessity for continued post-operative care.