You can access the Head Injury & Concussion template via Auto-Consultation > ardens CONSULTATIONS D to L. Alternatively, add these to your F12 favourites as a shortcut or search for them in the bottom left of S1.
The Head Injury & Concussion template is accessible directly via the minor injuries template and vice versa to allow for simple transition in clinical practice.
Use the tick box to document if the patients injury occurred in the last 48 hours and if applicable use the minor injuries tab to open the minor injuries template directly.
You can input manual information into the symptoms, mechanism of injury, pre-injury functioning or examination boxes or click the preset box to choose from the list of preset values to save you time during your consultation. Double click to add appropriate text.
Use the 'on anti-coagulant' and 'alcohol' drop down boxes to add code for anti-coagulant monitoring and alcohol consumption. You can directly access the Warfarin and DOAC monitoring templates along with the alcohol screening templates by clicking the corresponding tabs.
Input primary vital sign data into the BP, HR and RR boxes. If you need to record further vitals click . Use the Glasgow Coma Scale (GCS) box to input relevant objective data on the patients state of consciousness. If necessary click the GCS box to bring up the GCS scores template and input this information directly.
Access the headache diary and the radiology templates directly by clicking the corresponding tabs.
The impression section allows you to input code based on your clinical diagnosis. Click the drop down menu and select the option which is applicable and use the pencil icon to add additional free text if required.
Use the plan box in this section to document your clinical plan. Click the preset icon to add further preset information.
There are additional tick boxes at the bottom of the template to gently guide your clinical advice and management. Remember to tick the boxes in order to document that you have provided the appropriate advice.
To the right of these check boxes you can access the hyperlink to 'symptom checklist' which will lead you to a post-concussion symptom checklist PDF allowing you to assess for post-concussion syndrome.
You can directly access the head injury criteria which can guide your clinical decision making process and onward referral if clinically indicated.
You can access and provide your patient with a copy of the Gradual Return To Play (GRTP) care plan (tab found in the bottom right corner of the template). This is an extremely helpful tool aiding peoples safe return to activities of daily living and enjoyed sporting activities. Please see below a screenshot of the GRTP care plan.
You can click the child head injury tab to access the head injury advice sheet, this is a helpful tool for patients to refer to in the case of worsening symptoms. Finally, you can directly access the safeguarding risk score template allowing you to consider safeguarding when managing children.
If you need any help please click help & feedback at the top right hand corner of the template and click contact us if you wish to fill in the online form for help.