MINOR HEAD INJURY
MINOR HEAD INJURY
Encounter Form
Patient Name ____________________________________________DOB ___________________________________
Statement of Incident _____________________________________________________________________________
ALLERGIES ___________________Current Medications ______________________________ LMP _____________
Temp ________________ B/P _____________________ Pulse ______________________ Resp _______________
ASSESSMENT:
Yes No Headache
Yes No Disoriented or unclear about person, place and time
Yes No Loss of consciousness
Yes No Vital signs abnormal Yes No
Yes No Palpable skull defect ___ Tobacco Use
Yes No Abrasion or Laceration Describe __________________________ ___ Weight
Yes No Localized tenderness ___ Injury Prevention
Yes No Discharge from ears or nose Describe _______________________ ___ Drinking/Drug Use
Yes No Weakness on motor testing ___ School attendance
Yes No Demonstrated sensory loss ___ School Performance
Yes No Reflexes NOT intact ___ Physical Activity
Yes No Flexor plantar response ___ Sexual Behavior
Yes No Patient Stable ___ IZ's current
DX _____________________________________________________________
TREATMENT: Any laceration, abrasion or ecchymosis requires referral to MD or NP.
Yes No Dressing applied PRN
Yes No Patient able to move around freely
Yes No Tylenol 2 tabs
Yes No Information sheet given for parents
Yes No Rx Given __________________________________________
AMERICAN ACADEMY OF PEDIATRICS:
1. One Concussion – Out of the game.
2. Two Concussions – Out for the season.
3. Three Concussions – Out for school career.
Discharge Instructions Given Yes No
Return to Class Yes No Adult Parent Notified (Time) __________________ RTC in 24( for f/u
RN ___________________________________________ MD/NP ________________________________________
FOLLOW UP
DATE __________________________ TIME _______________
NOTES: ________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
PROVIDER ____________________________________________________
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