Head CT (trauma)

Incomplete Macros***
  • Head CT: No intracranial hyperdense lesions concerning for acute bleed. Cisterns patent. No loss of gray-white matter junction. Ventricles patent. No obvious skull fractures.
  • This is a preliminary interpretation by me. Institutional protocol in place which will alert current care team/patient for over-reads/changes/critical reads).

***Incomplete Macros are sample documentations that are designed for purposes of demonstrating a systematic approach to an emergent evaluation in synchrony with the documentation.  It could be useful for formulating an approach, serving as reminders for specific details that are often forgotten in the evaluation, and sample formating as well as usage of the medical lexicon in documentation.  This is NOT designed to be copied and pasted into a note as this is for obvious reasons fraught with medico-legal and as well clinical problems.  Additionally, as always, this is not intended to and cannot be used in place of clinical judgement and all clinical evaluations require the close involvement of an experienced faculty member (keep in mind that I am a resident, i.e. trainee).  

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