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Concussion Care Pathway

Date of last update: September, 2024

1. Record Keeping

Record keeping serves as a recall aid for the clinician of their interaction with the patient. It should concisely “tell the story” of the patient, and accurately reflect those interactions. Record-keeping requirements may be established by your jurisdiction’s standards of practice. These standards should be adhered to when maintaining your clinical records.

Subjective: Document the patient's reported symptoms using standardized tools like SCAT6/SCOAT6 symptom checklists, feelings, and feedback at each visit.

Objective: Record observable and measurable data such as physical examination findings and outcome measures.

Assessment: Provide a clinical assessment based on the subjective and objective data. Use SCAT6/SCOAT6 components to structure this, including cognitive function and neurological screening. Affirm or revise the diagnosis. Information about the patient's progress towards their goals could be recorded here.

Plan: Outline the treatment plan, any adjustments made, advice or other additional interventions or referrals. Any care or plan of care should reasonably be supported by the documented patient “story”. Include follow-up timelines and re-evaluation using SCAT6/SCOAT6 for consistency.

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