Resources and Memory //

Patient has suffered from minor blunt head trauma that occurred on the following data and time: [***]. The patient has a GCS of [***] [***] A Head CT was ordered based on the following indication: GCS < 15 Severe headache Vomiting (include if 2 times or greater), Coagulopathy Age 65+ Focal Neuro deficit Thrombocytopenia Signs of basilar skull fx, (raccoon eyes, Battle’s sign) Anticoagulant medication Dangerous mechanism of injury (include details of MOI) [***A Head CT was ordered as patient has LOC or post-traumatic amnesia AND one of the following: Headache Age 60-64 Drug/alcohol intoxication Short term memory deficit Post traumatic seizure Evidence of trauma above clavicles [***] A Head CT was not performed based on the 2008 ACEP Clinical Policy on Adult Head Trauma. [***] Exclusion statement: This patient is excluded from the QPP 415 measure based on the following: Ventricular shunt Brain tumor Multisystem trauma Pregnancy Currently on antiplatelet medication



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