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Recent blog post Qmetis Health

12 Jul Concussion Diagnosis and Documentation

Arthur Maerlender, PhD, ABPP-CN & Andrew Verreaux, BA


Concussion diagnosis is a clinical categorization that rests on symptom reporting. However, diagnostic criteria require certain signs and symptoms to be either ruled in or ruled out. Without an accepted biomarker the variability in clinical practices influences the quality of diagnoses. The quality and completeness of documentation through the course of injury are important factors for driving appropriate treatment and care.

This survey of clinical diagnostic reports was undertaken to demonstrate the utility of quantification of guideline adherence in concussion diagnosis.


A scoping review of guidelines and standards for diagnosis of concussion was undertaken to identify the best diagnostic practices based on evidence and expert consensus. Multiple expert panel reports, consensus conferences, and professional guidelines have been published and were used to survey a sample of existing diagnostic reports for completeness of documentation (see Appendix).  The review identified 16 best-practice principles with seven specific diagnostic criteria.  Within the 16 guidelines the criteria for diagnosis are represented.

The sample consisted of 62 case reports generated by 10 athletic trainers in their standard clinical practice. The reports were randomly selected from cases from the 2020-22 school years.  One independent reviewer reviewed each of the reports for documentation that reflected consideration of the 16 guidelines. 


Providing recommendations (97%), completing symptom examinations (89%), identifying the likely mechanism of injury (84%), administering the Standardized Assessment of Concussion (SAC 81%:  McCrea, 2001; McCrea et al., 1998)and the modified Balance Error Scoring System (mBESS 71%: Guskiewicz, 2011; Guskiewicz et al., 2013) were the guidelines most frequently met. Diagnoses were more often made within 48-hours than not, with the average time under 2-days. Less complete documentation was identified for rule-outs of loss of consciousness greater than 30 minutes (13%) and post traumatic amnesia greater than 24 hours (5%). Documenting cervical spine examinations (29%) and head trauma examinations (24%), together with the lack of reporting of the Glasgow Coma Scale (10%) represented important gaps in documentation.

About Dr. M.

Concussion Competencies books: US, Britain


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