Concussion Follow-Up & RTL/RTS Progress Note

Date: [date]

Injury Date: [injury date] Days Post-Injury: [number]

Visit Reason: [routine follow-up / clearance evaluation / symptom flare / school or work note / other]

History Source: [patient / parent / guardian / athletic trainer / other] (List all contributors as applicable)

Interval History

[Symptom trajectory since last visit] (Brief narrative summarizing overall change—better, worse, or same—with key drivers identified; note any new head impacts or red-flag symptoms; include intercurrent factors affecting recovery such as illness, medication changes, or sleep disruption.)

Symptom Scale: [scale name]

Total Score: [current score] (Prior: [previous score])

Symptoms Endorsed: [count]

Top Limiting Symptoms: [2-3 most impactful symptoms]

(If a standardized symptom scale was not administered, replace the above block with "Symptom scale not administered" and provide a concise narrative symptom summary instead.)

Current Functional Status: [school/work attendance and tolerance]; [screen tolerance]; [physical activity performed and symptom response]

RTL/RTS Status

RTL Stage: [not attending / partial with accommodations / full with accommodations / full without accommodations]

Current Accommodations: [brief list] (Include only if applicable)

RTS Stage: [current stage in progression]

Activity Performed: [type, duration, intensity]

Symptom Response: [symptoms during or after activity, resolution time]

Decision: [advance / hold / regress]

(For non-students or non-athletes, abbreviate to the applicable domain. If neither RTL nor RTS applies, document general activity tolerance instead.)

Objective

(Include only elements actually performed. Omit exam domains not assessed rather than documenting "not performed" for each.)

• Vitals: [relevant values] (Include orthostatics if autonomic symptoms present)
• Neuro Exam: [mental status, cranial nerves, coordination, gait, balance as examined]
• Vestibulo-Ocular: [maneuvers performed and symptom provocation]
• Cervical: [range of motion, palpation, provocative tests] (Include if neck pain or cervicogenic features present)
• Testing: [neurocognitive or exertional testing with brief interpretation]

Assessment

[Diagnosis] at [number] days post-injury. Recovery trajectory: [improving / plateaued / worsening]. [Predominant symptom phenotype if identifiable: vestibular, ocular, headache-dominant, cognitive-fatigue, cervicogenic, mood/sleep, autonomic, or mixed.] [Risk factors for prolonged recovery if present.] (Omit phenotype and risk factors if not clinically evident or relevant.)

Plan

• RTL/RTS Plan: [next stage]; [specific restrictions]; [minimum time before advancement]; [criteria for progression] (For students, include accommodation recommendations and duration.)
• Clearance: Cleared for [specific activities]. Not cleared for [specific activities]. Basis: [symptom-free at rest and with exertion; not masked by medication]. [Forms completed, supervision requirements if applicable.] (Include this block only when providing clearance. If not giving clearance, omit and document restrictions within RTL/RTS Plan above.)
• Symptom Management: [targeted treatments for dominant symptoms; referrals ordered]
• Follow-Up: [return interval]; [escalation criteria]; [referral triggers if symptoms persist beyond expected timeframe]
• Safety Precautions: [red flags requiring immediate evaluation] (Confirm instructions provided and to whom.)
• Communications: [school/work letters issued; athletic trainer coordination; other forms completed] (Include only if applicable)