Patient presents with signs and symptoms consistent with a spinal cord injury (SCI).  The mechanism of injury was [insert mechanism, e.g., motor vehicle accident, fall, sports injury].  The level of injury is suspected to be [insert level, e.g., cervical, thoracic, lumbar, sacral] based on neurological examination findings including [describe specific sensory and motor deficits, e.g., decreased sensation below T10, paraplegia, quadriplegia].  The American Spinal Injury Association Impairment Scale (AIS) grade is [insert AIS grade A-E] indicating the degree of completeness of the injury.  Associated injuries include [list associated injuries, e.g., fractures, traumatic brain injury].  Imaging studies, including [specify imaging, e.g., CT scan, MRI of the spine], revealed [describe imaging findings, e.g., compression fracture at C5, spinal cord edema].  Pain is reported as [describe pain characteristics, location, intensity].  The patient is currently hemodynamically stable.  Treatment plan includes [list treatment interventions, e.g., immobilization, surgical intervention, pain management, neurogenic bladder and bowel management, physical therapy, occupational therapy].  Prognosis for neurological recovery is discussed with the patient and family.  Patient education provided regarding SCI, potential complications such as autonomic dysreflexia, pressure sores, and deep vein thrombosis, and follow-up care.  Referral to specialized rehabilitation services is initiated.  ICD-10 code [insert appropriate ICD-10 code, e.g., S04.111A] is assigned.  This documentation supports medical necessity for ongoing care and treatment for this patient with spinal cord injury.