Intracranial Injury / Traumatic Brain Injury

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Intracranial Injury / Traumatic Brain Injury

Progression

  • When did disease process start
  • Initial or subsequent visit

Location

  • Site and laterality of the head injury-cerebrum, cerebellum, brainstem, epidural, subdural, subarachnoid, etc.

Acuity

  • N/A

Name

  • Type of intracranial injury/TBI-compression, concussion, hemorrhage (traumatic extradural hemorrhage, laceration, etc.)
  • Type of diffuse traumatic brain injury-such as diffuse axonal brain injury or focal traumatic brain injury

Necessary Procedures

  • Interventions as appropriate-Burr hole for evacuation, intracranial monitoring, repair of dura mater, ventriculostomy, etc.

Other

  • If patient experiences a loss of consciousness (LOC) and how long
  • If with any diffuse or focal cerebral edema
  • If patient has spinal cord damage or shock (also specify type of shock)

Why

  • Details of the injury (where, when, how) and all other comorbid conditions