Disability Services - Guidelines for Traumatic Brain Injury Documentation
A head injury or traumatic brain injury is a medical or clinical diagnosis. The individuals qualified to make such a diagnosis are practitioners who have been trained in the assessment of head injury/traumatic brain injury.
Such practitioners may include: neurologists; psychiatrists; physicians; licensed clinical, rehabilitation and school psychologists; and neuropsychologists. The attending/submitting practitioner must be an impartial individual who is not a member of the student's family.
All submitted evaluation reports must be typed on the attending clinician's letterhead stationery, and include the following information.
- Name of student
- Date(s) of injury(ies)
- History of concussion(s), including:
- Number of concussions with loss of consciousness and date(s) of occurrence
- Number of concussions without loss of consciousness and date(s) of occurrence
- Information regarding hospitalization for any of these injuries (where, date(s) length of stay)
- Information regarding surgery related to any of these injuries (where, date, type)
- Detailed information concerning post-concussive status and symptoms. Results of medical evaluation and/or psychological/educational testing, if completed, and must include the names of the standardized tests instruments completed including standard scores and percentiles
- Educational and psychological history pre-injury. Such information must include what services, i.e. special education, counseling, etc., or medications were prescribed for the student prior to or after the injury.
- List current medications (name and dosage) and the name of the prescribing physician/nurse practitioner
- Include a discussion of the post-concussion issues that may significantly impact the student's performance/functioning within the post-secondary academic environment.