Patient presents with a wound, characterized by [location: e.g., a 2 cm x 3 cm ulceration on the medial malleolus].  The wound bed appears [description: e.g., granulating with a small amount of yellow slough], and the surrounding skin is [description: e.g., erythematous and warm to the touch].  Wound edges are [description: e.g., well-defined and attached].  There is [presence or absence and description of exudate: e.g., moderate serous drainage present].  Patient reports [symptom: e.g., mild pain at the wound site, rated 3/10 on the pain scale].  No palpable fluctuance or crepitus noted.  Peripheral pulses are palpable and strong.  Assessment includes [differential diagnosis considerations: e.g., venous stasis ulcer, diabetic ulcer, pressure injury].  Diagnosis:  Chronic wound of [specified location].  Plan includes [treatment plan: e.g., wound debridement, application of antimicrobial dressing, compression therapy, and referral to wound care specialist].  Patient education provided regarding wound care, signs of infection, and importance of follow-up.  ICD-10 code [appropriate ICD-10 code: e.g., L97.419 - Non-pressure chronic ulcer of lower leg, unspecified site] assigned.  CPT codes for procedures performed documented separately.  Follow-up scheduled in [duration: e.g., one week].


Patient presents with an acute wound sustained [mechanism of injury: e.g., via laceration from a kitchen knife].  The wound is located on the [location: e.g., volar aspect of the left forearm] and measures [size: e.g., 5 cm in length].  Wound edges are [description: e.g., jagged and well-approximated].  Minimal bleeding noted.  Surrounding tissue exhibits mild erythema.  The patient reports [symptom: e.g., sharp pain at the wound site, 6/10 pain scale].  Neurovascular assessment of the distal extremity is intact.  Tetanus status updated.  Wound cleansed with normal saline and [treatment: e.g., closed with sutures].  Sterile dressing applied.  Diagnosis:  Acute laceration of the [specified location].  Patient education provided on wound care, signs of infection, and pain management.  ICD-10 code [appropriate ICD-10 code: e.g., S51.512A - Open wound of forearm, left arm, initial encounter] and appropriate CPT code for the laceration repair documented.  Follow-up appointment scheduled in [duration: e.g., ten days] for suture removal.

Patient presents for wound check.  Existing wound on the [location: e.g., right heel] is now [size: e.g., measuring 1 cm x 1 cm], demonstrating [improvement or deterioration: e.g., significant improvement from previous assessment].  Wound bed is now [description: e.g., completely granulating with no signs of necrosis or slough].  Surrounding skin is pink and intact.  Minimal serous drainage noted.  Patient reports [symptom: e.g., decreased pain].  Current treatment plan of [treatment plan: e.g., weekly dressing changes with alginate dressing] continued.  Diagnosis:  Healing wound of the [specified location].  Patient education reinforced regarding proper wound care and offloading techniques.  ICD-10 code [appropriate ICD-10 code: e.g., L97.429 - Non-pressure chronic ulcer of other part of lower leg, unspecified site] and appropriate CPT code for wound care documented.  Follow-up scheduled in [duration: e.g., two weeks].