Patient presents with signs and symptoms consistent with a traumatic brain injury (TBI).  Mechanism of injury includes [Insert specific mechanism, e.g., fall, motor vehicle accident, blunt force trauma].  On examination, patient exhibits [Insert specific findings, e.g., Glasgow Coma Scale score of X, altered mental status, loss of consciousness for X minutesduration, post-traumatic amnesia, headache, dizziness, nausea, vomiting].  Neurological examination reveals [Insert specific neurological findings, e.g., anisocoria, focal neurological deficits, cranial nerve palsies].  Imaging studies [Specify imaging modality, e.g., CT scan of the head without contrast, MRI brain] demonstrate [Insert imaging findings, e.g., cerebral contusion, subdural hematoma, subarachnoid hemorrhage, diffuse axonal injury].  Diagnosis of [Specify severity and type of TBI, e.g., mild traumatic brain injury, moderate traumatic brain injury, severe traumatic brain injury, concussion] is made based on clinical presentation, mechanism of injury, and imaging findings.  Differential diagnosis includes [Insert relevant differential diagnoses, e.g., post-concussive syndrome, intracranial hemorrhage].  Patient is being managed with [Insert treatment plan, e.g., close neurological monitoring, pain management, neuropsychological assessment, neurosurgical consultation].  Prognosis is [Insert prognosis based on severity and current presentation].  Patient education provided regarding TBI symptoms, recovery expectations, and follow-up care.  ICD-10 code S06.  Return precautions discussed.  Follow-up scheduled for [Date and time].