Patient presents with complaints consistent with spinal injury.  Onset of symptoms occurred on [Date of Onset] following [Mechanism of Injury - e.g., motor vehicle accident, fall].  Chief complaints include [List of symptoms - e.g., neck pain, back pain, numbness, tingling, weakness, paralysis].  Pain is described as [Pain Quality - e.g., sharp, dull, radiating, burning] and located in the [Location of Pain - e.g., cervical spine, thoracic spine, lumbar spine].  Neurological examination reveals [Neurological Findings - e.g., decreased sensation, diminished reflexes, motor deficits].  Spinal cord injury is suspected based on clinical presentation and mechanism of injury.  Differential diagnoses include vertebral fracture, disc herniation, spinal stenosis, and contusion.  Imaging studies, including [Type of Imaging - e.g., X-ray, CT scan, MRI], were ordered to evaluate the extent of the spinal injury and rule out other pathologies.  Preliminary imaging findings suggest [Imaging Findings - e.g., compression fracture, spinal cord edema].  Patient was stabilized with a cervical collar and administered pain medication.  Neurosurgical consultation was requested.  Treatment plan includes further neurological assessment, continuous monitoring of vital signs, and potential surgical intervention depending on imaging results and neurological status.  The patient's current American Spinal Injury Association Impairment Scale (AIS) grade is [AIS Grade] pending further evaluation.  ICD-10 code [ICD-10 Code - e.g., S32.001A,  T06.1X1A] is provisionally assigned, pending definitive diagnosis.  CPT codes for evaluation and management services, imaging studies, and procedures will be documented upon completion of services.