GWAS Concussion Training
GWAS Concussion Training
Documentation Trainer

What good documentation looks like

Poor documentation is one of the most common governance failures in pitchside care. For each scenario below, choose the best documentation statement.

"If it is not documented, it is difficult to prove it was assessed, explained or advised."

Poor note vs. better note

Insufficient
"Head injury advice given."
No mechanism, symptoms, decision, advice or handover recorded.
Better
"Polo fall approx 14:20 with helmet impact. Player reported headache and dizziness. No loss of consciousness, amnesia, repeated vomiting, severe neck pain or focal neurological deficit. Removed from play. No same-day return. Written UK grassroots/HPA concussion advice given. HCP/NHS 111 assessment within 24 hours advised. Responsible adult identified; urgent escalation advised for any deterioration or red flag."

Best note structure

1
Date and time
2
Sport / event
3
Mechanism
4
Witness account
5
Symptoms reported
6
Observed signs
7
Red flags checked (and result)
8
Decision made
9
Advice given — and to whom
10
Responsible adult identified
11
Escalation or referral
12
Refusal or pressure to return (if relevant)
Why documentation matters
Good documentation protects the patient, the clinician, the club, the event and GWAS. It is essential for governance, complaints handling, clinical review and CPD evidence.
Common mistake
Writing only "head injury advice given" after any head injury assessment. This records neither the assessment nor the decision, and leaves the clinician exposed.

Choose the best documentation — 5 exercises

Incident 1
Polo player falls from horse during a chukka. Reports headache. Removed from play.
Choose the best documentation:
Incident 2
Cyclist crashes at speed. Helmet cracked. Nausea and blurred vision. Not allowed to cycle home.
Choose the best documentation:
Incident 3
Junior rugby player keeps asking "what happened?" after a tackle. Removed. Parent notified.
Choose the best documentation:
Incident 4
Rider falls heavily. Severe neck pain and drowsiness. 999 called. Spinal movement minimised and protection maintained pending ambulance assessment.
Choose the best documentation:
Incident 5
Player wants to return. Coach is applying pressure. Clinical removal decision maintained.
Choose the best documentation:
This module teaches documentation standards for training purposes only. It does not replace GWAS clinical governance, PCR requirements or local policy.