Patient presents with complaints consistent with head injury.  Symptoms include [Specify symptoms e.g., headache, dizziness, nausea, vomiting, loss of consciousness, amnesia, confusion, blurred vision, tinnitus, etc.].  Onset of symptoms occurred [Timeframe] following [Mechanism of injury e.g., fall, motor vehicle accident, blunt trauma, sports injury, etc.].  Physical examination reveals [Document neurological exam findings e.g., Glasgow Coma Scale score, pupil size and reactivity, presence of any neurological deficits such as weakness, sensory changes, or cranial nerve abnormalities].  Scalp lacerations or contusions [Present or Absent, if present describe location and size].  Assessment includes consideration of concussion, intracranial hemorrhage, skull fracture, and post-concussive syndrome.  Differential diagnosis includes migraine, stroke, and seizure.  Ordered [Diagnostic tests e.g., CT scan of the head without contrast, MRI brain, skull x-ray, blood work].  Treatment plan includes [Specify treatment e.g., observation, pain management with [Medication], neurology consult, neurosurgery consult, wound care, patient education on head injury precautions and follow-up care].  Patient advised to return to the emergency department if symptoms worsen or new symptoms develop such as persistent vomiting, worsening headache, seizures, or altered mental status.  ICD-10 code considerations include S00.xxxx  depending on the specific injury.  Return to clinic scheduled for [Date].