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Editor in Chief & Update Author
Keith Pochick, MD, FACEP
Novant GoHealth Urgent Care
Urgent Care Peer Reviewer
Melinda Johnson, DNP, APRN, FNP-BC, AGACNP-BC, ENP-C
Vanderbilt University School of
Patrick O’Malley, MD
Newberry County Memorial Hospital
Patrick O’Malley, MD
Micelle Haydel, MD
Peer Reviewed By
Jeffrey J. Bazarian, MD, MPH; Jennifer Roth Maynard, MD; Linda Papa, MD, CM, MSc, CCFP, FRCP(C), FACEP
May 1, 2022
CME Expiration Date
May 1, 2025
4 AMA PRA Category 1 Credits™. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits
Head injury is a common presenting complaint to the UC setting and key information must be documented. The patient’s cognition may be impaired, so witness and/or family corroboration will be needed. Family or other caregivers should also be included in the discharge instruction review.
Obtain a detailed description of the event and mechanism of injury
Document presence or absence of LOC, duration of the LOC (if present), and any other associated symptoms such as headache, seizure, vision changes, vomiting, and repetitive questioning. Address any concomitant drug or alcohol use.
Ask about and document any bleeding disorders and anticoagulant or antiplatelet medications. Patients with a history of cardiac or cerebrovascular disease may not mention these medications, so query family or pharmacy records to confirm medication status.
Document the GCS score and any changes in the score.
Cognitive testing, pupillary response, and motor and balance testing should be performed and documented.
Utilize and document clinical decision rules such as PECARN, the New Orleans Criteria, or the Canadian CT Head Rule.
Review discharge instructions verbally and provide them in writing. Document that these were reviewed with a responsible family member or caregiver.
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