Patient presents with a chief complaint of pain, unspecified location and etiology.  The pain characteristics are described as (document pain quality e.g., sharp, dull, aching, burning, throbbing) and (document pain intensity using a validated pain scale e.g., 0-10 numerical rating scale, Wong-Baker FACES Pain Rating Scale).  The onset of pain is reported as (document onset e.g., gradual, sudden) and occurred approximately (document duration e.g., days, weeks, months) ago.  Aggravating factors include (document factors that worsen pain e.g., movement, rest, certain activities) and alleviating factors include (document factors that lessen pain e.g., medication, rest, ice, heat).  The patient denies any associated symptoms such as (document pertinent negatives e.g., fever, chills, nausea, vomiting, numbness, tingling, weakness).  Physical examination reveals (document relevant physical exam findings e.g., tenderness to palpation, limited range of motion, normal neurological exam).  Differential diagnosis includes (list potential diagnoses based on clinical presentation).  Further investigation is required to determine the underlying cause of the unspecified pain.  Initial treatment plan includes (document treatment plan e.g., pain management with over-the-counter analgesics such as ibuprofen or acetaminophen, referral for further evaluation, diagnostic testing such as imaging studies or laboratory work).  Patient education provided regarding pain management strategies, follow-up care, and when to seek immediate medical attention.  The patient verbalizes understanding of the plan.  Follow-up scheduled in (document timeframe e.g., one week, two weeks) to reassess pain and discuss further management.  ICD-10 code R52.9, Unspecified pain, is assigned.