For Mild Traumatic Brain Injury, You Can’t Rely on the Records

Most mild TBIs are not diagnosed in the emergency department.

Clinicians who treat and evaluate patients with mild traumatic brain injury weeks or months after the injury are often perplexed by emergency department records. The patients say that they felt confused and recollect only unclearly the accident and subsequent events, but the ED report notes that they were “A&Ox3,” with no documentation of confusion or amnesia. To determine the accuracy of ED documentation in patients with mild TBI, researchers compared results from retrospective chart reviews and structured patient interviews conducted in the ED.

Researchers prospectively identified 197 patients (age range, 16–70) who arrived in the EDs of an academic hospital and a level I trauma center within 48 hours of injury, with Glasgow Coma Scale sco…

Reviewing Author

Jonathan Silver, MD

Disclosures

RoyaltiesTextbook of Traumatic Brain Injury, 2nd and 3rd editions

Editorial BoardsUpToDate; Journal of Neuropsychiatry and Clinical Neuroscience

Leadership Positions in Professional SocietiesNorth American Brain Injury Association (Board Member); National Institute on Disability, Independent Living, and Rehabilitation Research (Chair of Data Monitoring Safety Board for study of donepezil on cognition after traumatic brain injury)

Jonathan Silver, MD

Disclosures

RoyaltiesTextbook of Traumatic Brain Injury, 2nd and 3rd editions

Editorial BoardsUpToDate; Journal of Neuropsychiatry and Clinical Neuroscience