Acute-Concussion-Evaluation-ACE-Care-Plan.pdf

ACUTE CONCUSSION EVALUATION (ACE)

CARE PLAN

PARENT / STUDENT REPORT

You have been diagnosed with a suspected concussion (also known as a mild traumatic brain injury). This personal plan is

based on your symptoms and is designed to help speed your recovery. Your careful attention to it can also prevent further

injury.

PARENT INFORMATION & HISTORY: Your child needs to see their primary care physician within 24-48 hours

Rest is the key. You should not participate in any high risk activities (e.j., sports, physical education (PE), riding a bike,

etc.) if you still have any of the symptoms below. It is important to limit activities that require a lot of thinking or

concentration (homework, job-related activities), as this can also make your symptoms worse. If you no longer have any

symptoms and believe that your concentration and things are back to normal, you can slowly and carefully return to your

daily activities. Children and teenagers will need help from their parents, teachers, PE teachers, coaches, or athletic

trainers to help monitor their recovery and return to activities.

Physical

Thinking

Emotional

Sleep

Headaches

Sensitivity to light

Mental Foggy

Irritability

Drowsiness

Nausea

Sensitivity to noise

Problems

concentrating

Sadness

Sleeping more than usual

Vomiting

Numbness/Tingling

Problems

remembering

Feeling more emotional

Sleeping less than usual

Fatigue

Visual problems

Feeling slowed

down

Nervousness

Trouble falling asleep

Dizziness

Balance Problems

RED FLAGS: Call 911, your doctor or go to your nearest emergency department if your child suddenly experiences

any of the following

Headaches that

worsen

Looks very drowsy, can’t be

awakened

Unusual behavior change

Slurred Speech

Seizures

Can’t recognize people or places

Repeated vomiting

Increasing irritability

Neck Pain

Weakness or numbness in arms or

legs

Increasing confusion

Loss of consciousness

GENERAL INFORMATION FOR PARENT AND STUDENT:

Returning to Daily Activities

1. Get lots of rest. Be sure to get enough sleep at night – no late nights. Keep the same bedtime weekdays and

weekends.

2. Take daytime naps or rest breaks when you feel tired or fatigued.

3. Limit physical activity as well as activities that require a lot of thinking or concentration. These activities can

make symptoms worse.

 Physical activity includes PE, sports practices, weight-training, running, exercising, heavy lifting, etc.

 Thinking and concentration activities (e.g., homework, classwork load, job-related activity).

4. Drink lots of fluids and eat carbohydrates or protein to main appropriate blood sugar levels.

5. As symptoms decrease, you may begin to gradually return to your daily activities. If symptoms worsen or

return, lessen your activities, and then try again to increase your activities gradually.

6. During recovery, it is normal to feel frustrated and sad when you do not feel right and you can’t be as active as usual.

7. Repeated evaluation of your symptoms is recommended to help guide recovery.

Student Name: _____________________________

DOB: ____________________ Age: _____________

Date: ___________________ ID/MR# Student #__________

Date of Injury: _____________________

Returning to School

1. If you (or your child) are still having symptoms of concussion you may need extra help to perform school-related

activities. As your (or your child’s) symptoms decrease during recovery, the extra help or supports can be removed

gradually.

2. Inform the teacher(s), school nurse, school psychologist or counselor, and administrator(s) about your (or your child’s)

injury and symptoms. School personnel should be instructed to watch for:

 Increased problems, paying attention or concentration

 Increased problems, remembering or learning new information

 Longer time needed to complete task or assignments

 Greater irritability, less able to cope with stress

 Symptoms worsen (e.g., headache, tiredness) when doing homework

EDUCATION CODE SECTION 49475 (THE CALIFORNIA CONCUSSION LAW)

An athlete who is suspected of sustaining a concussion or head injury in an athletic activity shall be immediately removed

from the activity for the remainder of the day, and shall not be permitted to return to the activity until he or she is evaluated

by a licensed health care provider, trained in the management of concussions, acting with the scope of his or her practice.

The athlete shall not be permitted to return to the activity until he or she receives written clearance to return to the activity

from that licensed health care provider.

Returning to Sports/ P.E. (Physical Activity)

1. You should NEVER return to play if you still have ANY symptoms – (Be sure that you do not have any symptoms

at rest and while doing any physical activity and/or activities that require a lot of thinking or concentration.)

2. Be sure that the PE teacher, coach, and/or athletic trainer are aware of your injury and symptoms.

3. It is normal to feel frustrated, sad and even angry because you cannot return to sports physical activity right away.

With any injury, a full recovery will reduce the chances of getting hurt again. If you are in sports it it is better to miss

one or two games than the whole season.

Gradual Return To Play (RTP) or Physical Activity Plan

1. No physical activity

2. Low levels of physical activity (i.e., symptoms do not come back during or after the activity). This includes walking,

light jogging, light stationary biking, and light weightlifting (lower weight, higher reps, no beach, and no squat).

3. Moderate levels of physical activity with body/head movement. This includes moderate jogging, brief running,

moderate-intensity stationary biking; moderate-intensity weightlifting (reduced time and/or reduced weight from the

typical routine).

4. Strenuous non-contact physical activity. This includes sprinting/running, high-intensity stationary biking, and

regular weightlifting routine, non-contact sport-specific drills (in 3 planes of movement).*** (If in regular PE or

sports)

5. Limited Contact/ Full contact in controlled practice. ** (If in sports)

6. Full contact in game play.** (If in sports)

*Minimum of 6 days to pass steps 1-4. Written physician (MD/ DO) clearance for return to play required after

successful completion of steps 1-4.

**MANDATORY: you must complete at least one contact practice before return to competition.

(Highly recommended that Step 5 be divided into 2 contact practice days.)

Parent Signature: Date:

_________________________ __________

□ I have reviewed this plan and give my

permission for school to contact physician for

consultation and exchange of information.

□ I decline medical care

Adopted: School Version of Acute Concussion Evaluation (ACE) Care Plan

“Heads Up: Brain Injury in Your Practice” tool kit form developed by CDC.

PHYSICIAN ORDERS FOR SCHOOL

(Yellow Sections for Physician Use)

NAME: ____________________________________ BIRTH DATE: ___________________________________

Returning to School

Until you (or your child) have fully recovered, the following supports are recommended: (M.D. check all that apply)

□ No return to school. Return on (date)___________________________________________________

□ Return to school with following supports. Review on (date)__________________________________

□ Shortened day. Recommend ____ hours per day until (date)_________________________________

□ Shortened classes (i.e., rest breaks during classes). Maximum class length: ______________minutes.

□ Allow extra time to complete coursework/assignments and test.

□ Lessen homework load by _______%. Maximum length or nightly homework: _____________minutes.

□ No significant classroom or standardized testing at this time.

□ Check for the return of symptoms (use symptom table on front page of this form) when doing activities that require

a lot of attention or concentration.

□ Take a rest breaks during the day as needed.

□ Request meeting of 504 or School Management Team to discuss this plan and needed supports.

The following are recommended at the present time: (M.D. check all that apply)

□ Do not return to PE class at this time

□ Return to PE class

□ Do not return to sports practices/games at this time

□ Gradual return to sports practices under the supervision of an appropriate health care provider (e.g., athletic trainer,

coach, or physical education teacher).

 Return to play should occur in gradual steps beginning with aerobic exercise only to increase your heart rate (e.g.,

stationary cycle); moving to increasing your heart rate with movement (e.g., running); then adding controlled

contact if appropriate; and finally return to sports competition.

 Pay careful attention to your symptoms and your thinking and concentration skills at each stage of activity. Move

to the next level of activity only if you do not experience any symptoms at each level. If your symptoms return, let

your health care provider know, return to the first level, and restart the program gradually.

Additional Instructions: __________________________________________________________________________

_______________________________________________________________________________________________

This referral plan is based on today’s evaluation:

□ Return to this office. Date/Time:________________________________________________

□ Refer to: Neurosurgery _____Neurology_____Sports Medicine_____Physiatrist_____Psychiatrist_____Other_____

□ Refer for neuropsychological testing

□ Other________________________________________________________________________________________

MEDICAL PROVIDER INFORMATION PARENT PERMISSION

Medical Provider (Print Name):____________________________________

Medical Provider Signature: ______________________________________

Address:_____________________________________________________

Or Stamp)

Phone: _________________________________