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HPI
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HISTORIAN
• • •
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MECHANISM OF INJURY
• • •
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MECHANISM OF INJURY
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LOCATION OF INJURY
• • •
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LOCATION OF INJURY
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TRAUMA TO THE HEAD EARLIER IN THE DAY?
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PLEASE DESCRIBE EARLIER TRAUMA
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LOC?
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DURATION OF LOC (IN MINUTES)
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SEIZURE LIKE ACTIVITY?
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DESCRIPTION OF SZ ACTIVITY
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PERTINENT POSITIVES
• • •
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PERTINENT NEGATIVES
• • •
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Additional notes
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REVIEW OF SYSTEMS
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Neuro (positive).
• • •
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Neuro (negative)
• • •
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Additional
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All systems otherwise negative.
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PHYSICAL EXAM
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Impact baseline test results
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Impact post concussion test results show
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Scalp location
• • •
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Scalp findings
• • •
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C-Spine TTP?
• • •
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Head AT/NC. Full Neuro Exam: Negative
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NEURO:
• • •
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Additional
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PE: Superficial
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Head to toe exam + No photophobia
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PE MACRO
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PAST HISTORY
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Medical Hx
• • •
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PMFSHx: Negative. Social: Student
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Past Surgical History
• • •
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Medical hx free text
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Family History: Non-contributory
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Surgical Hx
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Social Hx
• • •
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Family Hx
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Social History:
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MDM
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Baseline Assessment Score (0-20)
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Coordination Exam Score (0-20)
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PECARN Recommendation
• • •
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Status:
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Diagnosis:
• • •
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Status:
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Diagnosis:
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DISCHARGE
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POC Medications Given
• • •
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Point of Care Medications:
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Concussion Plan
• • •
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Follow up
• • •
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Plan Notes
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Discharge pt home
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Discharge pt to ER
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Mode of Transport to ER
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ER Transfer Comments
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Clinician Attestation
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