Sideline/Training Room Encounter Note

Sideline/Training Room Encounter Note

Date: [date]

Time of Injury/Onset: [time] (If unknown, briefly state why)

Time of Evaluation: [time]

Athlete: [name, DOB/age, sport, team, position]

Event: [game / practice / conditioning] at [venue]

Evaluator: [name, credentials, role]

(Time-stamp all critical events, interventions, and re-evaluations throughout this note.)

Safety Screen

Red Flag Assessment: [ABC status, mental status, c-spine concern, uncontrolled bleeding, cardiac symptoms, heat illness signs—document pertinent positives and negatives with key findings and immediate actions taken]

EAP/EMS Status: [not activated / EAP activated / EMS activated] at [time] (If activated, note destination and transport mode)

Vitals: [HR, BP, RR, SpO2, Temp as indicated] at [time] (If not obtained, briefly state why)

Chief Complaint & History

Chief Complaint: [one-sentence primary complaint]

[Mechanism of injury or illness and immediate functional impact. Key symptoms with severity and quality. Pertinent prior injuries or conditions to same area. Equipment/protective gear status if relevant to mechanism or RTP. Source of history: athlete / coach / ATC / parent / witness / video.] (4–8 sentences focusing on information that informs triage, assessment, and participation decisions.)

Focused Exam

(Include only systems relevant to the complaint. Note any limitations due to environment, time, or athlete condition.)

Exam Context: [sideline / training room / other] — [environmental constraints or exam limitations if applicable]

Musculoskeletal Findings: [inspection, palpation with specific landmarks, ROM, strength, neurovascular status, stability/special tests with results—compare to contralateral side] (Include when evaluating extremity or spine complaints)

Head/Brain Findings: [observable signs, symptom severity, cognitive screen results, balance/coordination, cervical spine screen, ocular-vestibular if performed, serial re-evaluation findings with time-stamps and trends] (Include for any head impact; if same-day return is considered, must document why concussion is no longer suspected based on objective findings and serial reassessment)

Other System Findings: [cardiopulmonary, abdominal, dermatologic, ENT, or other pertinent findings as indicated]

Functional Testing: [walk / jog / sprint / cut / hop / sport-specific tasks] — [tolerance, pain level, stability, confidence, performance] (Include when RTP is being considered)

Assessment & Disposition

Working Diagnosis: [diagnosis in order of priority; use qualifiers such as suspected / confirmed / unable to rule out as appropriate]

Participation Disposition: [return to play today (unrestricted) / return to play today (restricted/modified) / removed from play today / removed and referred / transferred by EMS / declined evaluation]

Rationale: [2–4 key findings that support the disposition decision]

RTP Requirements: [protective equipment, functional thresholds, recheck timing, stop rules] (Include if returning to play same day)

Removal Requirements: [immediate restrictions, observation requirements, transport plan] (Include if removed from play)

Plan & Communication

Notifications: [athlete / ATC / coach / parent-guardian / team physician] informed at [time] — [content of clearance status communicated]

Follow-up: [location, timing, specific elements to reassess]

Referrals: [specialty/service, urgency level, appointment details] (Include if referral made)

Return Precautions: [red flags and symptoms that should prompt immediate evaluation or EMS activation]

Instructions Provided: [type and key points] (Include if written instructions or handouts given)

Signature/Credentials: [name, credentials]

Documentation Time: [time]