Patient presents with signs and symptoms consistent with a head concussion, likely resulting from [mechanism of injury, e.g., fall, motor vehicle accident, sports injury].  Onset of symptoms occurred [timeframe, e.g., immediately, within minutes, hours] following the injury.  Patient reports [list of symptoms, e.g., headache, dizziness, nausea, vomiting, blurred vision, amnesia, confusion, difficulty concentrating, sensitivity to light or noise].  Neurological examination reveals [objective findings, e.g., normal pupillary response, intact extraocular movements, no focal neurological deficits, Glasgow Coma Scale score of 15].  Patient denies [relevant negatives, e.g., loss of consciousness, seizures, prior history of concussions].  Differential diagnosis includes [other potential diagnoses, e.g., post-concussion syndrome, mild traumatic brain injury, intracranial hemorrhage].  Assessment of concussion symptoms utilizes the SCAT5 symptom checklist.  Current symptoms are managed conservatively with [treatment plan, e.g., rest, over-the-counter pain relievers for headache, avoidance of strenuous activity, cognitive rest].  Patient education provided regarding concussion management, return to activity protocols, and warning signs of potential complications such as worsening headache, persistent vomiting, seizures, or altered mental status.  Follow-up scheduled in [timeframe, e.g., one week] to monitor symptom resolution and discuss return to learn or return to work plan.  ICD-10 code S06.0X assigned for concussion.  CPT codes for evaluation and management services documented based on complexity of visit.