Patient presents with complaints of low back pain, possibly a sacral fracture.  Onset of pain was (date of onset) following (mechanism of injury - e.g., fall, direct trauma).  Pain is described as (character of pain - e.g., sharp, dull, aching) and located in the sacral region, potentially radiating to (areas of radiation - e.g., buttocks, legs).  Patient reports (aggravating factors - e.g., sitting, standing, walking) and (alleviating factors - e.g., lying down, ice, medication).  Associated symptoms may include (associated symptoms - e.g., bowel or bladder dysfunction, numbness, tingling).  Physical examination reveals (physical exam findings - e.g., tenderness to palpation over the sacrum, limited range of motion, neurological deficits).  Imaging studies, including (imaging studies ordered - e.g., X-ray, CT scan, MRI) of the sacrum and pelvis, were ordered to evaluate for sacral insufficiency fracture, stress fracture, or traumatic fracture.  Differential diagnosis includes lumbar strain, sacroiliac joint dysfunction, and spinal stenosis.  Preliminary diagnosis is consistent with sacral fracture.  Treatment plan includes (treatment plan - e.g., pain management with analgesics, NSAIDs, physical therapy, surgical consultation if necessary).  Patient education provided regarding activity modification, weight-bearing restrictions, and fall prevention.  Follow-up appointment scheduled for (date of follow up) to reassess symptoms and discuss further management.  ICD-10 code (appropriate ICD-10 code - e.g., S32.XXX) is pending imaging confirmation.  This documentation supports medical coding and billing for sacral fracture care.