Patient presents with complaints consistent with possible skull fracture.  Chief complaint includes [Insert chief complaint e.g., headache, head injury, facial pain, altered mental status, etc.].  Mechanism of injury reported as [Insert mechanism of injury e.g., fall, motor vehicle accident, blunt force trauma, assault, etc.].  On physical examination, notable findings include [Insert positive findings e.g., scalp laceration, tenderness to palpation, ecchymosis, periorbital edema, Battle sign, raccoon eyes, cerebrospinal fluid rhinorrhea or otorrhea, neurological deficits, etc.].  Negative findings include [Insert pertinent negatives e.g., no loss of consciousness, no nausea or vomiting, no focal neurological deficits, etc.].  Differential diagnosis includes skull fracture, concussion, intracranial hemorrhage, contusion, scalp laceration.  Imaging studies ordered include [Insert ordered imaging studies e.g., skull x-ray, CT scan of the head, CT scan of the face, etc.].  Preliminary diagnosis of [Insert type of skull fracture if known e.g., linear skull fracture, depressed skull fracture, basilar skull fracture, etc.] is suspected based on clinical presentation and mechanism of injury.  Patient is stable and alert, oriented to person, place, and time.  Neurological exam reveals [Insert detailed neurological findings e.g., Glasgow Coma Scale score, cranial nerve assessment, motor strength, sensory exam, deep tendon reflexes, etc.]. Treatment plan includes [Insert treatment plan e.g., pain management, observation, neurosurgical consultation, admission for monitoring, antibiotics for CSF leak, surgical intervention if indicated, etc.].  Patient education provided regarding signs and symptoms of complications such as intracranial bleeding, infection, and neurological deficits.  Follow-up care with [Specialty e.g., neurosurgery, primary care physician] scheduled in [Timeframe].  ICD-10 code S02.  Further evaluation and management pending imaging results and clinical course.