Patient presents with complaints consistent with urge incontinence, characterized by involuntary urine leakage accompanied by a sudden, compelling desire to void.  Symptoms include urgency, frequency, nocturia, and difficulty delaying urination.  Onset of symptoms was reported as (gradual/sudden) approximately (duration) ago.  Patient reports (number) episodes of incontinence per day, typically associated with (triggers such as coughing, sneezing, laughing, or physical exertion).  No history of dysuria, hematuria, or fever is reported.  Physical examination revealed (normal/abnormal) pelvic floor muscle strength.  Post-void residual was measured at (volume) mL.  Assessment includes urge incontinence, likely due to (detrusor overactivity/other suspected cause).  Differential diagnoses considered include stress incontinence, mixed incontinence, and overflow incontinence.  Plan includes behavioral interventions such as bladder training and pelvic floor muscle exercises.  Patient education provided regarding fluid management and lifestyle modifications.  Pharmacological management may be considered if behavioral interventions are insufficient.  Follow-up scheduled in (timeframe) to assess response to treatment and adjust plan as needed.  ICD-10 code N39.41 (urge incontinence) assigned.  Medical necessity for treatment documented.