Date:
Patient:
Admitting Physician:
Current Progress Note:
History of Present Illness:
Briefly describe the mechanism of injury (e.g., motor vehicle accident, fall)
Level of consciousness on presentation (e.g., Glasgow Coma Scale score)
Loss of consciousness (LOC) duration (if applicable)
Post-traumatic amnesia (PTA) duration (if known)
Symptoms since injury (e.g., headache, dizziness, nausea, vomiting, confusion)
Prior medical history relevant to TBI (e.g., medications, bleeding disorders)
Physical Examination:
Summarize the pertinent neurological findings, including:
Mental status (alertness, orientation)
Cranial nerves
Motor strength and coordination
Sensory function
Speech and language
Pupillary response
Imaging Studies:
Describe the type of imaging studies performed (e.g., CT scan, MRI)
Summarize the findings, including:
Type of TBI (e.g., concussion, contusion, hematoma)
Location of injury
Presence of any intracranial bleeding or edema
Laboratory Studies:
List relevant laboratory tests performed (e.g., CBC, electrolytes, coagulation studies)
Briefly mention any abnormal findings
Assessment:
State the severity of the TBI based on clinical presentation and imaging studies (e.g., mild, moderate, severe)
Discuss potential complications of TBI (e.g., increased intracranial pressure, seizures, meningitis)
Plan:
Outline the treatment plan, including:
Medications (e.g., pain management, anti-seizure prophylaxis)
Monitoring of vital signs and neurological status
Management of intracranial pressure (if needed)
Speech and language therapy (if indicated)
Physical and occupational therapy (if indicated)
Disposition (e.g., ICU monitoring, transfer to rehabilitation unit, discharge home)
Discharge instructions with education on activity restrictions, signs and symptoms to watch for, follow-up appointments
Education:
Document patient and family education regarding TBI, recovery process, potential complications, and medication adherence.
Follow-up:
Schedule follow-up appointments with relevant specialists (e.g., neurosurgeon, rehabilitation physician)
Note: This is a template and should be adapted to the specific details of each patient.
Additional Information:
You may also want to include sections for:
Social history (e.g., substance abuse, helmet use)
Functional status (e.g., activities of daily living)
Prognosis
Refer to relevant clinical guidelines for the management of TBI
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of TBI