Guide to Clinical Documentation Essay

Guide to Clinical Documentation Essay

It is mandatory that the patient undergoes a detailed assessment including a comprehensive history and physical exam and review of systems that would focus on the head and neck region and the central nervous system.  An integrated health assessment is vital for making an accurate diagnosis which will ensure that the most appropriate plan of care is implemented. Therefore, the history should focus on capturing details such as: the type of trauma, whether there was any form of trauma to the skin, skull or scalp, if the patient lost consciousness, memory, motor co-ordination and balance and how long it lasted (Ball et al., 2015).  The patient should also be assessed for associated symptoms such as feelings of drowsy, vomiting, nausea, dizziness and light sensitivity. Radiological imaging tests such as a head MRI/CT Scan based on the assessment results may also prove to be essential. The purpose of this assessment is to establish whether or not the patient experienced a concussion and the degree of its severity. Alternatively, the Acute Concussion Evaluation (ACE) form may be used as a tool in making this determination (Sullivan, 2012). Guide to Clinical Documentation Essay


            Should the diagnosis of a concussion be made, then the patient should not be allowed to play until when all symptoms will be totally resolved in at least 7 days. Instead, the guidelines provided by the International Conference on Concussion in Sport should immediately be implemented through a stepwise program with maximum supervision. After the first day, the symptoms may be milder revealing some gradual progress thus should not engage in any physical activity. Instead he should receive complete cognitive rest until a time when he is asymptomatic and can begin light aerobic exercises. It is however necessary that at least 24 hours is observed between the steps before fully returning to play. It should be noted that, the client’s risk for greater injury in case he plays football within 3 days is high. Besides, from a medical perspective, it would be unethical to clear the patient for him to play in the game within 3 days (Tingle & Cribb, 2014).


Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.

Tingle, J. & Cribb, A. (2014). Nursing law and ethics (4th ed.). Chichester, UK: Wiley Blackwell. Guide to Clinical Documentation Essay

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