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General Practitioner Template

Head Injury

A professional General Practitioner template for healthcare professionals.
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Specialty

General Practitioner

Used

40 times

Type

Note

Last edited

19/09/2024

Created by

Jothikumar Gounder

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About this template

This head injury documentation template is designed for general practitioners to efficiently record and assess patients with head injuries. It includes sections for the reason for visit, detailed history of the injury, examination findings, and advice given. The template ensures comprehensive documentation of critical factors such as loss of consciousness, neurological deficits, and indications for further imaging like a CT scan. This template is ideal for GPs managing acute head injuries and helps streamline the documentation process in Heidi, ensuring all relevant clinical information is captured accurately.

Preview template

Reason for visit: Head injury following a fall from a bicycle. History: The injury occurred 2 hours ago. The patient fell off their bicycle and hit their head on the pavement. There was a brief loss of consciousness for approximately 1 minute, followed by vomiting. The patient reports a worsening headache since the incident. No amnesia or fitting episodes were noted. There has been no change in behavior since the injury. The patient does not have a clotting disorder and is not on anticoagulants. There is no evidence of drug or alcohol intoxication. No safeguarding concerns were identified. Examination: GCS score: 14/15 Pupil reactivity: Reactive bilaterally Pulse rate: 88 bpm Oxygen saturation: 98% on room air Spine examination findings: No tenderness or deformity noted Skull examination findings: Bruising on the right temporal region No signs of base of skull fracture No focal neurological deficits observed Cardiovascular: Heart sounds: Normal S1 and S2 No murmurs detected Respiratory: No respiratory distress Air entry: Equal bilaterally No crackles or rhonchi Abdomen, Pelvis: No tenderness noted Limbs: No abnormalities detected Indication for CT head: Due to the brief loss of consciousness and vomiting Head injury advice given: Advised to monitor for any worsening symptoms, such as increased drowsiness, persistent vomiting, or confusion, and to seek immediate medical attention if these occur.

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