Patient presents with psychotic symptoms consistent with an Unspecified Psychotic Disorder (F29).  The patient exhibits positive symptoms of psychosis, including disorganized thinking and unusual perceptual experiences, though these do not clearly meet the criteria for schizophrenia, schizophreniform disorder, brief psychotic disorder, schizoaffective disorder, delusional disorder, or other specified psychotic disorders.  Differential diagnosis considered other psychotic disorders, substance-induced psychotic disorder, psychotic disorder due to another medical condition, and bipolar disorder with psychotic features.  The patient's symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.  Onset and duration of symptoms were explored.  Family history of mental illness was reviewed.  Mental status examination revealed [insert specific observations related to appearance, behavior, mood, affect, speech, thought process, thought content, perception, cognition, insight, and judgment].  Current medications include [list current medications].  Treatment plan includes initiation of [medication name and dosage] for symptom management, referral to psychiatry for further evaluation and diagnostic clarification, and individual therapy focused on coping skills and social support.  Psychoeducation regarding psychosis, medication adherence, and early warning signs of relapse was provided.  Prognosis, risks, and benefits of treatment were discussed.  Patient expressed understanding and agreement with the treatment plan.  Follow-up appointment scheduled in [timeframe] to monitor symptom response and adjust treatment as needed.  ICD-10 code F29 will be used for billing and coding purposes.  Medical necessity for ongoing treatment will be documented and justified as per payer requirements.