Concussion Evaluation and Management Note

Date/Time of Encounter: [Date and time of evaluation]

Setting: [clinic / urgent care / ED follow-up / athletic training room]

Patient Age: [Age]

Historian(s): [patient / parent/guardian / coach / athletic trainer / witness / other]

Date/Time of Injury: [Exact time or best estimate with basis if uncertain]

Time Since Injury: [Hours/days since injury]

Injury Context: [Sport/activity, position, level of play, equipment; or non-sport mechanism such as fall, MVC, assault]

Prior Care Since Injury: [none / sideline evaluation / urgent care / ED / imaging completed]

Chief Complaint

[Single-line reason for visit with brief context, e.g., "Head injury—suspected concussion after [mechanism] [timeframe]; [primary symptoms]."]

Red Flag Screen

(Indicate present/absent/unknown for each item. If patient cannot reliably answer, mark "unknown" and document collateral history efforts.)

• Worsening severe headache: [present / absent / unknown]
• Repeated vomiting: [present / absent / unknown]
• Seizure: [present / absent / unknown]
• Focal weakness or numbness: [present / absent / unknown]
• Slurred speech: [present / absent / unknown]
• Marked confusion or agitation: [present / absent / unknown]
• Inability to awaken or excessive somnolence: [present / absent / unknown]
• Unequal pupils: [present / absent / unknown]
• Worsening neurologic status: [present / absent / unknown]
• Neck pain concerning for cervical injury: [present / absent / unknown]
• Anticoagulant use with concerning features: [present / absent / unknown]
• Significant mechanism with concern for intracranial injury: [present / absent / unknown]

Disposition: [ED transfer now / imaging and urgent escalation indicated / no danger signs present—appropriate for outpatient concussion management with return precautions]

Collateral/Comments: [Collateral history sources, reliability, and reasons for any "unknown" responses] (Include only if applicable.)

History of Present Illness

[Injury event description: what/when/where, mechanism details including direct head impact vs acceleration/deceleration, impact location, number of impacts, removal from play, protective equipment]

[Immediate neurologic features: LOC yes/no/unknown with estimated duration; post-traumatic amnesia (retrograde/anterograde) with duration; confusion; balance problems; cervical symptoms] (State "unknown" when unclear; do not infer.)

[Symptom timeline: onset immediate/delayed, peak period, current trajectory improving/stable/worsening, triggers such as exertion, screens, reading, light/noise]

[Treatments tried and response: rest, activity modifications, sleep changes, medications with name/dose/frequency, hydration]

[Functional impact: school/work attendance and performance, physical activity tolerance, driving status, mood changes noted by patient or family]

Concussion History and Risk Factors

• Prior concussions: [number, approximate dates, typical recovery duration, prolonged symptoms, prior imaging/specialty care, or unknown]
• Factors associated with prolonged recovery: [migraine/headache disorder / learning disorder or ADHD / anxiety/depression / sleep disorder / vestibular disorders / none reported]
• Medical risk factors: [anticoagulants / bleeding disorder / seizure disorder / none reported]
• Baseline pre-injury symptoms: [headache / dizziness / visual symptoms / none reported]

Medications and Allergies

• Current medications: [List names, doses, frequencies; note anticoagulants, psychoactive medications, sedatives]
• Allergies: [Drug/other allergies with reactions]
• Relevant social/safety history: [Substance use; helmet/seatbelt use] (Include only if pertinent.)

Symptom Scoring

Tool: [Tool name and version] — [acute assessment within ~72 hours / subacute assessment]

• Date/Time administered: [Date and time]
• Number of symptoms endorsed: [#]
• Total symptom severity score: [Score]
• Condition: [at rest / after exertion]

[Prior scores with dates and trend statement] (Include for follow-up visits.)

(If formal tool cannot be completed due to age, language, or cognitive limitations, document the reason, alternate approach used, and limitations.)

Physical Examination

(Document only elements actually examined. If portions are deferred, document "not assessed" with reason.)

• Vitals: BP [value], HR [value], RR [value], SpO2 [value], Temp [value], Pain [value]. [Orthostatic vitals if indicated]
• General/Head/Neck: [Appearance, distress level, photophobia/phonophobia behaviors, scalp/facial findings]. Cervical spine: [midline tenderness, ROM, paraspinal tenderness, symptom provocation, cervical injury screening]
• Neurologic: Mental status: [alertness, orientation, speech, attention]. Cranial nerves: [findings]. Motor: [gross strength, tone, pronator drift]. Sensory: [gross light touch, focal deficits]. Coordination: [finger-nose-finger, rapid alternating movements]. Gait: [normal and tandem gait findings]
• Vestibular/Oculomotor Screening:
  • Pupils and extraocular movements: [findings]; Nystagmus: [present/absent, direction]
  • Smooth pursuits: [findings]; Symptoms provoked: [headache / dizziness / nausea / fogginess / none]
  • Saccades (horizontal/vertical): [findings]; Symptoms provoked: [headache / dizziness / nausea / fogginess / none]
  • Near point of convergence: [distance in cm]; Symptoms provoked: [headache / dizziness / nausea / fogginess / none]
  • Vestibulo-ocular reflex (horizontal/vertical): [findings]; Symptoms provoked: [headache / dizziness / nausea / fogginess / none]
  • Visual motion sensitivity: [findings]; Symptoms provoked: [headache / dizziness / nausea / fogginess / none]
• Balance: [mBESS conditions and error counts]. Tandem gait: [time and errors]
• Cognitive Screening: [Orientation, immediate memory, concentration, delayed recall] (If computerized testing reviewed: test name, date, interpretation.)

Data Reviewed

(Include only when external data was reviewed.)

• Outside records: [ED note / imaging report / athletic trainer documentation]
• Imaging reviewed: [Modality, date, findings, interpreting source]
• Collateral history: [Source and summary]
• Clinician communication: [Who, when, key points]

Assessment

Primary diagnosis: [Suspected concussion/mTBI / Concussion confirmed] — [with LOC / without LOC / LOC unknown], [acute / subacute] phase. Predominant symptom domains: [vestibular / headache / cognitive-fatigue / ocular / mood / mixed]

• Differential diagnoses: [intracranial hemorrhage with imaging rationale / cervical strain / vestibular pathology / migraine exacerbation / other] (Include when relevant.)
• Risk stratification: [Risk factors for prolonged recovery present/absent with details]
• Safety considerations: [Home supervision, ability to follow precautions, barriers]
• Clinical course: [Trajectory summary; acknowledge evolving injury when early]

Plan

Safety and Return Precautions: Written and verbal precautions provided to [recipient]. Responsible observer: [name/relationship]. Return to emergency care if: worsening severe headache, repeated vomiting, seizure, focal weakness/numbness, slurred speech, marked confusion/agitation, inability to awaken, unequal pupils, worsening neurologic status, or new concerning symptoms.

Activity Guidance: [Initial relative rest recommendation with duration]. Transition to symptom-limited physical and cognitive activity. Restricted from activities with head impact risk until cleared.

Return-to-Learn Plan: (Include for students.)

• Expected return to school: [Date/estimate]
• Accommodations: [reduced workload / rest breaks / extended time / reduced screens / quiet testing / note-taking support]
• Staged progression: Step 0 (home cognitive activity) → Step 1 (partial day with accommodations) → Step 2 (full day with accommodations) → Step 3 (full academics). Regress if symptoms worsen beyond mild/brief increase.
• School contact: [Name/role]
• Formal supports: [504 / IEP / none recommended]

Return-to-Sport Plan: (Include for athletes.)

• No same-day return to play.
• Clearance prerequisites: Back to full non-sport activities at baseline, asymptomatic at rest and with exertion, exam normal/at baseline.
• Staged progression (minimum 24 hours per step; regress if symptoms recur): Step 1 (regular non-sport activities) → Step 2 (light aerobic) → Step 3 (moderate activity) → Step 4 (heavy non-contact) → Step 5 (practice/full contact) → Step 6 (competition).
• Progression supervisor: [athletic trainer / coach / parent / clinician]
• Clearance status: [Not cleared for contact/collision sport / Cleared for non-contact only / Cleared for full participation]. Reassess: [timing].

Symptom Management: [Headache: analgesics, hydration, sleep, trigger avoidance]. [Sleep: hygiene and schedule]. [Vestibular/oculomotor: activity modification, vestibular therapy referral]. [Cognitive/fatigue: pacing, rest breaks, gradual loading]. [Mood: normalize responses, screening, referral if indicated]. (Include only applicable interventions.)

Imaging: [Not indicated—rationale and safety net / Ordered: modality, indication, urgency, counseling provided]

Referrals: [Concussion specialist / vestibular rehabilitation / neuropsychology / neurology / behavioral health] — indication and timing. (Consider if symptoms worsen, persist >2–4 weeks, marked vestibular/ocular dysfunction, significant headache, mood symptoms, or academic impairment.)

Follow-up: [Interval, e.g., 7 days or sooner if worsening]. Track: symptom scores, school/work functioning, exercise tolerance, vestibular/oculomotor exam if initially abnormal.

Patient Education: Handouts provided: [concussion education / RTL letter / RTS protocol]. [Driving/work restrictions discussed]. Questions answered.

(If injury time is uncertain, document best estimate with basis. If red flag items cannot be assessed, mark "unknown" with explanation. If symptom scoring cannot be completed, document reason and alternate approach. Do not infer absence of symptoms, red flags, or exam abnormalities—document only what is explicitly stated or assessed.)