InjureFree Blog

Why Properly Documenting Concussions is Vital to Athlete Health

More than 15% of high school athletes will sustain one or more concussions and unfortunately, the prevalence multiples among collegiate athletes. Athletic Trainers (ATs) are often the first line of support available to athletes following a concussion. They also play an integral role in educating athletes, coaches, and parents about concussions; how to identify them and manage symptoms. The big picture goal of an AT post-concussion is to help the athlete safely return to play. To effectively prevent concussions, manage acute concussion symptoms and monitor recovery, documentation is essential. 

It’s important that ATs maintain an accurate record of an athlete's health history. Past injuries and multiple concussions can affect an athlete’s return to play, so this information is crucial to reference following a concussion to make more informed care decisions. In addition, ATs must thoroughly document the concussion in real time. As best practice, documentation should also include symptom progression during and after the recovery phase. At minimum, documentation should include a full description of the injury, including, but not limited to the following:

  • Date, time, and location of injury
  • Mechanism of injury (contact or non-contact)
  • Affected areas 
  • Did the athlete lose consciousness? If so, for how long? 

To provide quality care and safely get athletes back in the game, ATs need to understand return to play protocols. As there is no single test available to determine when an athlete is ready to return to play, it’s imperative that ATs monitor symptoms, ensuring that an athlete has been symptom free for at least 24 hours and can attend a full day of school without symptoms. 

Finally, ATs are responsible for staying compliant with current laws, policies, and guidelines regarding concussions protocols. Remember, proper documentation can save athlete’s lives. Click here to learn more about sports concussion policies and laws.




  1. DePadilla L, Miller GF, Jones SE, Peterson AB, Breiding MJ. Self-Reported Concussions from Playing a Sport or Being Physically Active Among High School Students – United States, 2017. MMWR Morb Mortal Wkly Rep. 2018;67(24):682-685.
  2. Return to play after a concussion. Play After a Concussion | Children's Hospital Colorado. (2023). Retrieved February 5, 2023, from 
  3. Wallace J, Covassin T, Nogle S, Gould D, Kovan J. Knowledge of Concussion and Reporting Behaviors in High School Athletes With or Without Access to an Athletic Trainer. J Athl Train. 2017 Mar;52(3):228-235.

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