Patient presents with uncontrolled type 2 diabetes mellitus.  Symptoms include persistent hyperglycemia, polyuria, polydipsia, and polyphagia.  The patient reports recent weight loss and increased fatigue.  HbA1c is elevated at [insert value, e.g., 9.5%], exceeding the target range for glycemic control.  Fasting blood glucose levels are consistently above target  [insert range or value, e.g., >130 mgdL].  Review of systems reveals ongoing symptoms suggestive of diabetic complications, including peripheral neuropathy with complaints of numbness and tingling in the lower extremities.  Assessment indicates uncontrolled diabetes mellitus type 2, inadequately managed with current regimen of [insert current treatment, e.g., metformin 1000mg twice daily].  Plan includes intensification of current medication regimen  [describe change, e.g., increasing metformin to 2000mg twice daily] and initiation of [new medication or therapy, e.g., insulin therapy].  Patient education regarding diabetes management, including dietary modifications, increased physical activity, and self-monitoring of blood glucose, was reinforced.  Follow-up appointment scheduled in two weeks to assess response to therapy and adjust treatment plan as needed.  Diagnosis codes include E11.9 for type 2 diabetes mellitus without complications, and E11.65 for type 2 diabetes mellitus with hyperglycemia.  Additional codes may be added based on documented complications.  Medical nutrition therapy and diabetes self-management training referrals are pending.