Acute Sports Injury Visit Note

Date/Time: [Encounter date and time]

Location: [Clinic / urgent care / sideline follow-up / ED follow-up]

Clinician: [Name and role]

Patient: [Name, DOB, MRN per local policy]

Injury Date/Time: [Exact or best estimate] (If unknown, document reason: unwitnessed, patient unsure, or limited by amnesia.)

Time Since Injury: [Duration from injury to encounter]

Sport/Activity: [Sport or activity, level (youth/high school/college/adult), position or event]

Venue/Equipment: [Playing surface and relevant protective equipment]

History Source: [Patient / parent / coach / athletic trainer / EMS] (Note if interpreter used.)

Chief Complaint

[Symptom, body part, laterality, and context in single concise line]

Red Flag Screen

[Red flag status] (If no red flags: "Red flag screen negative: no altered mental status, syncope, hemodynamic instability, neurologic deficits, absent pulses, compartment concerns, open wounds, or gross deformity." If any red flag present, document findings and complete items below.)

• Specific finding(s): [Red flag finding(s) with anatomic detail]
• Immediate actions taken: [Immobilization / ED transfer / EMS activation / medications] (Include timing.)
• Reassessment after intervention: [Updated status and vitals]
• Consults/handoff: [Who was contacted; handoff details]

History of Present Illness

[Injury event details: mechanism (contact vs non-contact, forces involved, limb position), immediate consequences (ability to continue play, collapse vs walked off, weight-bearing ability), audible or subjective cues (pop, snap)]

[On-field or sideline care: who provided care, treatments administered (ice, compression, splinting, taping, medications), protocols initiated]

[Symptom evolution: pain severity and quality, swelling and bruising progression, mechanical symptoms (locking, catching, instability, giving way), neurologic symptoms (numbness, tingling, weakness)]

[Current functional status: ability to walk, bear weight, or use affected limb; baseline athletic level for context]

[Pertinent negatives supporting clinical decision-making] (If history limited by distress, amnesia, or lack of collateral, state explicitly.)

[Concussion-relevant history: LOC, retrograde/anterograde amnesia, headache, dizziness, visual changes, nausea, cognitive/behavioral changes] (Include only if head impact, whiplash mechanism, or concerning symptoms present.)

Relevant History

(Include only if clinically relevant to urgency, imaging decisions, bleeding risk, or healing; otherwise omit this section entirely.)

• Prior injuries/surgeries (same region): [Details]
• Bleeding risk: [Bleeding disorders / anticoagulants / antiplatelets]
• Conditions affecting healing: [Diabetes / immunocompromise / connective tissue disease]
• Current medications: [List, highlighting analgesics taken today]
• Allergies: [Relevant to treatment]
• Tetanus status: [Date] (If wounds present.)
• Concussion history: [Number of prior concussions, recovery duration, prolonged symptoms, migraine history, learning or mental health factors] (If head injury suspected.)

Physical Examination

Vitals: [BP, HR, RR, Temp, SpO2, pain score]

General: [Appearance, distress level, gait pattern, weight-bearing ability, need for assistance]

Injury-Focused Examination

• Inspection: [Swelling, ecchymosis, deformity, wounds, skin integrity with anatomic locations]
• Palpation: [Point tenderness at specific landmarks, crepitus]
• Range of Motion: [Active and passive ROM, limitations, comparison to uninjured side]
• Strength: [Graded; note if limited by pain vs true weakness]
• Stability/Special Tests: [Tests performed and results] (Only clinically appropriate and safe acute tests.)
• Functional Testing: [Weight-bearing ability, four-step test, or other functional assessment if safe]

Neurovascular Examination

(Always document explicitly for extremity injuries. If intervention performed, document before AND after.)

• Perfusion: [Capillary refill, skin temperature, color]
• Pulses: [Distal pulses; comparison to uninjured side]
• Sensation: [Intact / diminished in relevant nerve distributions]
• Motor: [Key movements for relevant nerve function]

Head and Cervical Spine Examination

(Include when head impact, whiplash mechanism, altered behavior, headache, dizziness, nausea, vomiting, amnesia, or neck pain present.)

• Mental status/orientation/speech: [Findings]
• Gait and balance: [Findings if safe to assess]
• Pupils and extraocular movements: [Findings]
• Cervical spine: [Midline tenderness; ROM if safe]
• Focal neurologic deficits: [Present / absent; describe if present]

Diagnostics

• Imaging ordered/performed: [Modality, body part, laterality, views; preliminary or final results]
• Clinical decision rule applied: [Rule name and specific criteria observed] (Document criteria met/unmet rather than only naming the rule.)
• Rationale if no imaging: [Decision rule negative / low-risk mechanism / reassuring exam findings]
• External records reviewed: [Athletic trainer notes / EMS documentation / prior imaging / orthopedic records]

Assessment

(Problem-oriented list by clinical urgency. Use anatomic specificity and laterality. Do not state "no fracture" without imaging; instead document level of suspicion with supporting findings.)

1. [Working diagnosis with laterality]: [Key supporting findings from mechanism, examination, imaging; severity if meaningful; differential diagnoses remaining plausible]

2. [Working diagnosis with laterality]: [Key supporting findings; severity; differential] (Add additional problems as needed.)

Plan

(Organize by problem when multiple injuries present.)

Acute Management

• RICE/Protection: [Rest, ice, compression, elevation instructions]
• Analgesia: [Medication, dose, route, frequency] (Verify no contraindications.)
• Medications administered in clinic: [Drug, dose, route, time]

Immobilization and Support

• Support device: [None / brace / boot / splint / sling / cast with type and laterality]
• Rationale: [Suspected fracture / instability / pain control / protection during diagnostic uncertainty]
• Weight-bearing status: [Weight-bearing as tolerated / partial / non-weight-bearing]
• Assistive devices: [Crutches / walker provided and fitted]
• Duration: [Timeframe until re-evaluation]

Activity Restrictions

• Sport participation: [No play / modified practice / non-contact only / full return]
• Lifting/usage limits: [Specific restrictions]
• Work/school modifications: [Accommodations needed]
• Concussion-specific: [No same-day return to play; symptom-limited activity; staged return-to-sport under supervision; school accommodations] (If applicable.)

Referrals and Follow-up

• Imaging: [Ordered / deferred with rationale]
• Specialty referrals: [Specialty and urgency: immediate/ED, urgent 24–72 hours, routine]
• Follow-up: [Timeframe; criteria for earlier return]

Patient Counseling

• Key points discussed: [Expected course, home care, risks reviewed]
• Understanding confirmed: [Patient/parent verbalizes understanding and agrees with plan]

Return Precautions

[Criteria to seek immediate care: worsening pain or swelling, increasing numbness or weakness, cool or pale limb, uncontrolled pain, worsening inability to bear weight, fever or drainage if wound present] (For head injuries, include: worsening headache, repeated vomiting, seizure, increasing confusion, focal weakness, slurred speech.)

Procedures

(Include only when procedures performed.)

• Procedure: [Name, indication, site with laterality]
• Consent: [Obtained; risks discussed]
• Technique: [Details; splint type, position, padding if applicable]
• Neurovascular status: [Before and after procedure]
• Patient tolerance: [Tolerated well / complications]
• Post-procedure instructions: [Care and follow-up]

Disposition

• Disposition: [Home / ED transfer by ambulance or private vehicle / direct specialty referral]
• Condition at discharge: [Stable / pain controlled; ambulatory status]
• Handoff communication: [Who contacted; summary provided] (If applicable.)