Patient presents with signs and symptoms consistent with a head hematoma.  Onset of [onset timeframe, e.g., acute, subacute, chronic] symptoms occurred following [mechanism of injury, e.g., fall, blunt trauma, MVA].  Location of hematoma is [location, e.g., scalp, subdural, epidural, intracerebral].  Patient exhibits [symptoms, e.g., headache, dizziness, nausea, vomiting, altered mental status, focal neurological deficits, loss of consciousness].  Physical examination reveals [physical findings, e.g., palpable scalp swelling, ecchymosis, tenderness, neurological deficits].  Differential diagnosis includes [differential diagnoses, e.g., concussion, contusion, skull fracture, other intracranial hemorrhage].  Imaging studies, including [imaging modalities, e.g., CT scan of the head without contrast, MRI of the brain], were ordered to evaluate the extent and location of the hematoma.  Preliminary imaging findings indicate [imaging findings, e.g., presence, size, and location of hematoma].  Assessment: Head injury with hematoma.  Plan:  Close neurological monitoring, pain management with [pain management plan, e.g., acetaminophen, ibuprofen], [treatment plan, e.g., observation, surgical intervention, neurosurgical consult]. Patient education provided regarding head injury precautions, signs and symptoms of worsening condition, and follow-up care.  Return precautions discussed.  ICD-10 code [ICD-10 code, e.g., S06.0, S06.5] considered.  CPT codes for evaluation and management services will be determined based on complexity of visit.  Continued monitoring and reassessment as clinically indicated.