CDE Detailed Report

Disease: Sport Related Concussion
Sub-Domain: Cognitive Assessment
CRF: Acute Concussion Evaluation (ACE)

Displaying 1 - 50 of 59
CDE ID CDE Name Variable Name Definition Short Description Question Text Permissible Values Description Data Type Disease Specific Instructions Disease Specific Reference Population Classification (e.g., Core) Version Number Version Date CRF Name (CRF Module / Guideline) Sub Domain Name Domain Name Size Input Restrictions Min Value Max Value Measurement Type External Id Loinc External Id Snomed External Id caDSR External Id CDISC
C05400 Injury date time InjDateTime Date (and time, if applicable and known) of injury Date (and time, if applicable and known) of injury Date/Time of Injury Date or Date & Time Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Free-Form Entry

C54359 Acute Concussion Evaluation (ACE) ? Symptom check list exertion physical activity indicator ACESymptomChkLstExrtPhysActInd Indicator of whether subject/participant symptoms worsen with physical activity since injury as related to the Acute Concussion Evaluation (ACE). Indicator of whether subject/participant symptoms worsen with physical activity since injury as related to the Acute Concussion Evaluation (ACE). Exertion: Do these symptoms worsen with physical activity? Yes;No;N/A Yes;No;N/A Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:29:51.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Single Pre-Defined Value Selected

C54338 Acute Concussion Evaluation (ACE) ? Injury cause type sports text ACEInjuryCauseTypSportsTxt Text specifying the cause of the impact injury as related to the Acute Concussion Evaluation (ACE). Text specifying the cause of the impact injury as related to the Acute Concussion Evaluation (ACE). Sports (specify) Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:29:51.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points 255

Free-Form Entry

C54370 Acute Concussion Evaluation (ACE) - Risk factors protracted recovery migraine headache family text ACERskFcPtrctRcvMgrnHeadFamTxt Text describing which family member(s) had/have migraine headache as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Text describing which family member(s) had/have migraine headache as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Provide detail of family members with history of migraine Alphanumeric

Provide detail of family members with history of migraine

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:22:56.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points 100

Free-Form Entry

C54349 Acute Concussion Evaluation (ACE) ? Symptom check list type ACESymptomChkLstTyp Type of symptoms subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE). Type of symptoms subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE). Since the injury, has the person experienced any of these symptoms any more than jusual today or in the past day? Balance problems;Difficulty concentrating;Difficulty remembering;Dizziness;Drowsiness;Fatigue;Feeling mentally foggy;Feeling slowed down;Headache;Irritability;More emotional;Nausea;Nervousness;Numbness/tingling;Sadness;Sensitivity to light;Sensitivity to noise;Sleeping less than usual;Sleeping more than usual;Trouble falling asleep;Visual problems;Vomiting Balance problems;Difficulty concentrating;Difficulty remembering;Dizziness;Drowsiness;Fatigue;Feeling mentally foggy;Feeling slowed down;Headache;Irritability;More emotional;Nausea;Nervousness;Numbness/tingling;Sadness;Sensitivity to light;Sensitivity to noise;Sleeping less than usual;Sleeping more than usual;Trouble falling asleep;Visual problems;Vomiting Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Lovell MR, Collins MW. Neuropsychological assessment of the college football player. J Head Trauma Rehabil. 1998;13(2):9-26. Adult;Pediatric Supplemental 1.00 2017-02-27 20:22:56.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Multiple Pre-Defined Values Selected

C54394 Acute Concussion Evaluation (ACE) ? Follow-up action plan referral physician type ACEFollowupActPlnReferPhyscTyp Type follow-up plan of action referral physician for subject/participant as related to the Acute Concussion Evaluation (ACE). Type follow-up plan of action referral physician for subject/participant as related to the Acute Concussion Evaluation (ACE). Physician: Neurology;Neurosurgery;Other;Physiatrist;Psychiatrist;Sports Medicine Neurology;Neurosurgery;Other;Physiatrist;Psychiatrist;Sports Medicine Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:22:56.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Multiple Pre-Defined Values Selected

C17409 Visit date VisitDate Date of interview or visit (actually the date when data in the form were captured) Date of interview or visit Date: Date or Date & Time Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 3.00 2013-06-21 00:00:00.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Free-Form Entry

C54360 Acute Concussion Evaluation (ACE) ? Symptom check list exertion cognitive activity indicator ACESymptomChkLstExrtCognActInd Indicator of whether subject/participant symptoms worsen with cognitive activity since injury as related to the Acute Concussion Evaluation (ACE). Indicator of whether subject/participant symptoms worsen with cognitive activity since injury as related to the Acute Concussion Evaluation (ACE). Exertion: Do these symptoms worsen with cognitive activity? Yes;No;N/A Yes;No;N/A Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:29:51.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Single Pre-Defined Value Selected

C54339 Acute Concussion Evaluation (ACE) ? Injury cause type other text ACEInjuryCauseTypOthrTxt Text specifying another cause of the impact injury as related to the Acute Concussion Evaluation (ACE). Text specifying another cause of the impact injury as related to the Acute Concussion Evaluation (ACE). Other Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:29:51.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points 255

Free-Form Entry

C54371 Acute Concussion Evaluation (ACE) ? Risk factors protracted recovery developmental history type ACERskFacProtrctRcvDevlopHxTyp Type of developmental history as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Type of developmental history as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Developmental History Attention Deficit Hyperactivity Disorder (ADHD);Learning disability;Other developmental disorder Attention Deficit Hyperactivity Disorder (ADHD);Learning disability;Other developmental disorder Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:22:56.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Single Pre-Defined Value Selected

C54350 Acute Concussion Evaluation (ACE) ? Symptom check list physical indicator ACESymptomChkLstPhysInd Indicator of whether subject/participant has experienced physical symptoms since injury as related to the Acute Concussion Evaluation (ACE). Indicator of whether subject/participant has experienced physical symptoms since injury as related to the Acute Concussion Evaluation (ACE). PHYSICAL (0-10) 0;1 0=No;1=Yes Alphanumeric

Indicate presence of each symptom (0=No 1=Yes).

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:29:51.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Single Pre-Defined Value Selected

C54395 Acute Concussion Evaluation (ACE) ? Follow-up action plan referral physician type other text ACEFlowupActPlnReferPhysTypOTH Test of other type follow-up plan of action referral physician for subject/participant as related to the Acute Concussion Evaluation (ACE). Test of other type follow-up plan of action referral physician for subject/participant as related to the Acute Concussion Evaluation (ACE). Other Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:22:56.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points 255

Free-Form Entry

C19247 Subject ID SubIDNam Subject identification ID Subject identification ID ID/MR# Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2014-06-05 13:10:49.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points 255

Free-Form Entry

C54361 Acute Concussion Evaluation (ACE) ? Symptom check list overall rating status ACESympChkLstOverallRateStat Status of how different the subject/participant is acting from usual self after injury as related to the Acute Concussion Evaluation (ACE). Status of how different the subject/participant is acting from usual self after injury as related to the Acute Concussion Evaluation (ACE). Overall Rating: How different is the person acting compared to his/her usual self? 0;1;2;3;4;5;6 0 - Normal;1;2;3;4;5;6 - Very Different Alphanumeric

Circle "0" (Normal) to "6" (Very Different)

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-28 12:25:41.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Multiple Pre-Defined Values Selected

C54340 Acute Concussion Evaluation (ACE) ? Amnesia before no memory events indicator ACEAmnesiaBfNoMemEvntsInd Indicator of whether subject/participant had no memory of events before (retrograde) amnesia as related to the Acute Concussion Evaluation (ACE). IIndicator of whether subject/participant had no memory of events before (retrograde) amnesia as related to the Acute Concussion Evaluation (ACE). Amnesia Before (Retrograde) Are there any events just BEFORE th einjury that you/person has no memory of (even brief)? No;Yes No;Yes Alphanumeric

Even seconds to minutes of memory loss can be predictive of outcome. Recent research has indicated that amnesia may be up to 4-10 times more predictive of symptoms and cognitive deficits following concussion than is LOC (less than 1 minute).

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:29:51.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Single Pre-Defined Value Selected

C54372 Acute Concussion Evaluation (ACE) - Risk factors protracted recovery other developmental disorder other text ACERskFacPrtrctRcvOthDevlDsOTH Text describing other developmental disorder as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Text describing other developmental disorder as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Other developmental disorder Alphanumeric

Specify the other developmental disorder.

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:22:56.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points 255

Free-Form Entry

C54351 Acute Concussion Evaluation (ACE) ? Symptom check list physical total count ACESymptomChkLstPhysTotCt Total count of physical symptoms subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE). Total count of physical symptoms subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE). PHYSICAL Total (0-10) Numeric Values

Sum total number of symptoms present per area, and sum all four areas into a Total Symptom Score (score range 0–22)(Note: most sleep symptoms are only applicable after a night has passed since the injury.

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:29:51.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Free-Form Entry

0 10
C54396 Acute Concussion Evaluation (ACE) ? ACE reporter text ACEReporterTxt Person/individual administering the Acute Concussion Evaluation (ACE). Person/individual administering the Acute Concussion Evaluation (ACE). ACE completed by: Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:22:56.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points 255

Free-Form Entry

C21117 Subject name SubjectName Name of subject/participant. Name of subject/participant. Patient Name Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2015-06-12 15:16:39.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points 255

Free-Form Entry

C54362 Acute Concussion Evaluation (ACE) ? Risk factors protracted recovery history type ACERiskFacProtrctRecovHxTyp Type of risk factors that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Type of risk factors that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Risk Factors for Protracted Recovery Concussion History;Headache History;Developmental History;Psychiatric History Concussion History;Headache History;Developmental History;Psychiatric History Alphanumeric

Check all that apply

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:22:56.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Multiple Pre-Defined Values Selected

C54341 Acute Concussion Evaluation (ACE) ? Amnesia before no memory events duration ACEAmnesiaBfNoMemEvntsDur Duration of subject's/participant's length of amnesia before injury as related to the Acute Concussion Evaluation (ACE). Duration of subject's/participant's length of amnesia before injury as related to the Acute Concussion Evaluation (ACE). Amnesia Before (Retrograde) Duration Numeric Values Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:29:51.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Free-Form Entry

C54375 Acute Concussion Evaluation (ACE) ? Risk factors protracted recovery psychiatric history type ACERskFacPrtrctRcvPsychHxTyp Type psychiatric history disorder as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Type psychiatric history disorder as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Psychiatric History Anxiety;Depression;Other psychiatric disorder;Sleep disorder Anxiety;Depression;Other psychiatric disorder;Sleep disorder Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:22:56.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Multiple Pre-Defined Values Selected

C54352 Acute Concussion Evaluation (ACE) ? Symptom check list cognitive indicator ACESymptomChkLstCogntvInd Indicator of whether subject/participant has experienced cognitive symptoms since injury as related to the Acute Concussion Evaluation (ACE). Indicator of whether subject/participant has experienced cognitive symptoms since injury as related to the Acute Concussion Evaluation (ACE). COGNITIVE (4) 0;1 0=No;1=Yes Alphanumeric

Indicate presence of each symptom (0=No 1=Yes).

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:29:51.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Single Pre-Defined Value Selected

C54331 Acute Concussion Evaluation (ACE) - Person obtaining report type ACEPersonObtRprtTyp The type indicating who the report was obtained by, as part of the Acute Concussion Evaluation (ACE) The type indicating who the report was obtained by, as part of the Acute Concussion Evaluation (ACE) Reporter: Patient;Parent;Spouse;Other Patient;Parent;Spouse;Other Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2016-12-05 10:04:25.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Single Pre-Defined Value Selected

C54363 Acute Concussion Evaluation (ACE) ? Risk factors protracted recovery concussion history indicator ACERiskFacProtrctRecvConcHxTyp Indicator of whether concussion history is a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Indicator of whether concussion history is a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Concussion History? No;Yes No;Yes Alphanumeric

Assess the number and date(s) of prior concussions, duration of symptoms for each injury, and whether less biomechanical force resulted in re-injury.

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:22:56.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Multiple Pre-Defined Values Selected

C54342 Acute Concussion Evaluation (ACE) ? Amnesia after no memory events indicator ACEAmnesiaAftrNoMemEvntsInd Indicator of whether subject/participant had no memory of events after (anterograde) amnesia as related to the Acute Concussion Evaluation (ACE). Indicator of whether subject/participant had no memory of events after (anterograde) amnesia as related to the Acute Concussion Evaluation (ACE). Amnesia After (Anterograde) Are there any events just AFTER the injury that you/ person has no memory of (even brief)? No;Yes No;Yes Alphanumeric

Even seconds to minutes of memory loss can be predictive of outcome. Recent research has indicated that amnesia may be up to 4-10 times more predictive of symptoms and cognitive deficits following concussion than is LOC (less than 1 minute).

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:29:51.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Single Pre-Defined Value Selected

C54377 Acute Concussion Evaluation (ACE) - Risk factors protracted recovery other psychiatric disorder other text ACERskFacPrtrctRcvPsycDsordOTH Text for other psychiatric disorder as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Text for other psychiatric disorder as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Other psychiatric disorder Alphanumeric

Specify other psychiatric disorder.

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:22:56.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points 100

Free-Form Entry

C54353 Acute Concussion Evaluation (ACE) ? Symptom check list cognitive total count ACESymptomChkLstCogntvTotCt Total count of cognitive symptoms subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE). Total count of cognitive symptoms subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE). COGNITIVE Total (0-4) Numeric Values

Sum total number of symptoms present per area, and sum all four areas into a Total Symptom Score (score range 0–22)(Note: most sleep symptoms are only applicable after a night has passed since the injury.

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:29:51.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Free-Form Entry

0 4
C54332 Person obtaining report other text PersonObtRprtOtherText Text specifying another means of obtaining the report Text specifying another means of obtaining the report Other Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2016-12-05 10:11:55.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points 255

Free-Form Entry

C54364 Acute Concussion Evaluation (ACE) ? Risk factors protracted recovery concussion history previous value ACERskFacPrtrctRcvCncHxPrevVal Value of the number of previous concussions as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Value of the number of previous concussions as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Previous # 1;2;3;4;5;6+ 1;2;3;4;5;6+ Numeric Values

Assess the number and date(s) of prior concussions, duration of symptoms for each injury, and whether less biomechanical force resulted in re-injury.

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:22:56.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Single Pre-Defined Value Selected

C54343 Acute Concussion Evaluation (ACE) ? Amnesia after no memory events duration ACEAmnesiaAftrNoMemEvntsDur Duration of subject's/participant's length of amnesia after (anterograde) injury as related to the Acute Concussion Evaluation (ACE). Duration of subject's/participant's length of amnesia after (anterograde) injury as related to the Acute Concussion Evaluation (ACE). Amnesia After (Anterograde) Duration Numeric Values Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:29:51.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Free-Form Entry

C54378 Acute Concussion Evaluation (ACE) ? Risk factors protracted recovery comorbid medical disorders medication usage text ACERskFcPtrctRcvComrdDisMedTxt Text for other comorbid medical disorders or medication usage as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Text for other comorbid medical disorders or medication usage as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). List other comorbid medical disorders or medication usage (e.g., hypothyroid, seizures) Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:22:56.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points 255

Free-Form Entry

C54354 Acute Concussion Evaluation (ACE) ? Symptom check list emotional indicator ACESymptomChkLstEmotnlInd Indicator of whether subject/participant has experienced emotional symptoms since injury as related to the Acute Concussion Evaluation (ACE). Indicator of whether subject/participant has experienced emotional symptoms since injury as related to the Acute Concussion Evaluation (ACE). EMOTIONAL (4) 0;1 0=No;1=Yes Alphanumeric

Indicate presence of each symptom (0=No 1=Yes).

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:29:51.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Single Pre-Defined Value Selected

C54333 Acute Concussion Evaluation (ACE) ? Injury description text ACEInjuryDescriptnTxt Text of injury description as related to the Acute Concussion Evaluation (ACE) Text of injury description as related to the Acute Concussion Evaluation (ACE) Injury Description Alphanumeric

Obtain description of the injury.

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 19:20:57.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points 255

Free-Form Entry

C54365 Acute Concussion Evaluation (ACE) ? Risk factors protracted recovery concussion history duration type ACERskFacPrtrctRcvConcHxDurTyp Type of duration of longest symptom regarding concussion history as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Type of duration of longest symptom regarding concussion history as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Longest symptom duration Days;Weeks;Months;years Days;Weeks;Months;years Alphanumeric

Assess the number and date(s) of prior concussions, duration of symptoms for each injury, and whether less biomechanical force resulted in re-injury.

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:22:56.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Multiple Pre-Defined Values Selected

C54344 Acute Concussion Evaluation (ACE) ? Loss of consciousness indicator ACELossConsciousnessInd Indicator of whether subject/participant had loss of consciousness as related to the Acute Concussion Evaluation (ACE). Indicator of whether subject/participant had loss of consciousness as related to the Acute Concussion Evaluation (ACE). Loss of consciousness: Did you/ person lose consciousness? No;Yes No;Yes Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:29:51.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Single Pre-Defined Value Selected

C54380 Acute Concussion Evaluation (ACE) ? Red flags acute emergency management type ACERedFlagAcuteEmergMgmtTyp Type of red flags for acute emergency management as related to the Acute Concussion Evaluation (ACE). Type of red flags for acute emergency management as related to the Acute Concussion Evaluation (ACE). RED FLAGS for acute emergency management: Can't recognize people or places;Change in state of consciousness;Focal neurologic signs;Headaches that worsen;Increasing confusion or irritability;Looks very drowsy/ can't be awakened;Neck pain;Repeated vomiting;Seizures;Unusual behavioral change;Weakness or numbness in arms/legs Can't recognize people or places;Change in state of consciousness;Focal neurologic signs;Headaches that worsen;Increasing confusion or irritability;Looks very drowsy/ can't be awakened;Neck pain;Repeated vomiting;Seizures;Unusual behavioral change;Weakness or numbness in arms/legs Alphanumeric

Refer to the emergency department with sudden onset of any of the following:

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:22:56.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Multiple Pre-Defined Values Selected

C54355 Acute Concussion Evaluation (ACE) ? Symptom check list emotional total count ACESymptomChkLstEmotnlTotCt Total count of emotional symptoms subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE). Total count of emotional symptoms subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE). EMOTIONAL Total (0-4) Numeric Values

Sum total number of symptoms present per area, and sum all four areas into a Total Symptom Score (score range 0–22)(Note: most sleep symptoms are only applicable after a night has passed since the injury.

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:29:51.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Free-Form Entry

0 4
C54334 Acute Concussion Evaluation (ACE) ? Evidence direct blow head indicator ACEEvidnceDirctBlowHeadInd Indicator whether injury is due to a blow to the head as related to the Acute Concussion Evaluation (ACE). Indicator whether injury is due to a blow to the head as related to the Acute Concussion Evaluation (ACE). Is there evidence of a forcible blow to the head (direct or indirect)? No;Yes;Unknown No;Yes;Unknown Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:02:13.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Single Pre-Defined Value Selected

C54366 Acute Concussion Evaluation (ACE) ? Risk factors protracted recovery multiple concussion force reinjury indicator ACERskFcPtrcRcvMltCncFrcRnjInd Indicator of whether multiple concussions occur with less force caused reinjury is a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Indicator of whether multiple concussions occur with less force caused reinjury is a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). If multiple concussions, less force caused reinjury? No;Yes No;Yes Alphanumeric

Assess the number and date(s) of prior concussions, duration of symptoms for each injury, and whether less biomechanical force resulted in re-injury.

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:22:56.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Multiple Pre-Defined Values Selected

C54345 Acute Concussion Evaluation (ACE) ? Loss of consciousness duration ACELossConsciousnessDur Duration of the subject/participant's loss of consciousness as related to the Acute Concussion Evaluation (ACE). Duration of the subject/participant's loss of consciousness as related to the Acute Concussion Evaluation (ACE). Loss of consciousness duration Numeric Values Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:29:51.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Free-Form Entry

C54390 Acute Concussion Evaluation (ACE) ? Diagnosis (ICD) concussion type ACEDiagnosisIcdConcussionTyp Type of ICD diagnosis of concussion as related to the Acute Concussion Evaluation (ACE). Type of ICD diagnosis of concussion as related to the Acute Concussion Evaluation (ACE). Diagnosis (ICD) No diagnosis;850.0 Concussion without Loss of Consciousness (LOC);850.1 Concussion with Loss of Consciousness (LOC);850.9 Concussion (Unspecified);Other (854) No diagnosis;850.0 Concussion without Loss of Consciousness (LOC);850.1 Concussion with Loss of Consciousness (LOC);850.9 Concussion (Unspecified);Other (854) Alphanumeric

The following ICD diagnostic codes may be applicable.
850.0 (Concussion with no loss of consciousness) – Positive injury description with evidence of forcible direct/indirect blow to the head (A1a); plus evidence of active symptoms (B) of any type and number related to the trauma (Total Symptom Score >0); no evidence of LOC (A5), skull fracture or intracranial injury (A1b).
850.1 (Concussion, with brief loss of consciousness 0); positive evidence of LOC (A5), skull fracture or intracranial injury (A1b).
850.9 (Concussion, unspecified) – Positive injury description with evidence of forcible direct/indirect blow to the head (A1a); plus evidence of active symptoms (B) of any type and number related to the trauma (Total Symptom Score >0); unclear/unknown injury details; unclear evidence of LOC (A5), no skull fracture or intracranial injury.
Other diagnosis – If patient presents with a positive injury description and associated symptoms, but additional evidence of intracranial injury (A1b) such as from neuroimaging, a moderate TBI and diagnostic category of 854 (Intracranial injury) should be considered.

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:22:56.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Multiple Pre-Defined Values Selected

C54356 Acute Concussion Evaluation (ACE) ? Symptom check list sleep indicator ACESymptomChkLstSleepInd Indicator of whether subject/participant has experienced sleep symptoms since injury as related to the Acute Concussion Evaluation (ACE). Indicator of whether subject/participant has experienced sleep symptoms since injury as related to the Acute Concussion Evaluation (ACE). SLEEP (4) 0;1;N/A 0=No;1=Yes;N/A Alphanumeric

Indicate presence of each symptom (0=No 1=Yes).

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:29:51.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Single Pre-Defined Value Selected

C54335 Acute Concussion Evaluation (ACE) ? Evidence intracranial injury skull fracture indicator ACEEvidnceIntraCrnSkulFrctrInd Indicator whether injury is due to an intracranial skull fracture as related to f the Acute Concussion Evaluation (ACE). Indicator whether injury is due to an intracranial skull fracture as related to f the Acute Concussion Evaluation (ACE). Is there eveidence of intracranial injury or skull fracture? No;Yes;Unknown No;Yes;Unknown Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:02:13.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Single Pre-Defined Value Selected

C54367 Acute Concussion Evaluation (ACE) ? Risk factors protracted recovery headache history indicator ACERiskFacProtrctRecvHeadHxTyp Indicator of whether headache history is a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Indicator of whether headache history is a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE). Headache History? No;Yes No;Yes Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:22:56.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Multiple Pre-Defined Values Selected

C54346 Acute Concussion Evaluation (ACE) ? Early signs type ACEEarlySignsTyp Type of early signs that may have been observed after subject/patient injury as related to the Acute Concussion Evaluation (ACE). Type of early signs that may have been observed after subject/patient injury as related to the Acute Concussion Evaluation (ACE). EARLY SIGNS: Appears dazed or confused;Is confused about events;Answers questions slowly;Repeats questions;Forgetful (recent info) Appears dazed or confused;Is confused about events;Answers questions slowly;Repeats questions;Forgetful (recent info) Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:22:56.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Multiple Pre-Defined Values Selected

C54391 Acute Concussion Evaluation (ACE) ? Follow-up action plan type ACEFollowupActionPlanTyp Type of follow-up plan of action for subject/participant as related to the Acute Concussion Evaluation (ACE). Type of follow-up plan of action for subject/participant as related to the Acute Concussion Evaluation (ACE). Follow-Up Action Plan No Follow-Up Needed;Physician/Clinician Office Monitoring;Referral No Follow-Up Needed;Physician/Clinician Office Monitoring;Referral Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:22:56.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Multiple Pre-Defined Values Selected

C00007 Birth date BirthDate Date (and time, if applicable and known) the participant/subject was born Date (and time, if applicable and known) the participant/subject was born DOB: Date or Date & Time Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 3.00 2013-07-25 08:54:08.2 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Free-Form Entry

793
C54357 Acute Concussion Evaluation (ACE) ? Symptom check list sleep total count ACESymptomChkLstSleepTotCt Total count of sleep symptoms subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE). Total count of sleep symptoms subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE). SLEEP Total(0-4) Numeric Values

Sum total number of symptoms present per area, and sum all four areas into a Total Symptom Score (score range 0–22)(Note: most sleep symptoms are only applicable after a night has passed since the injury.

Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:29:51.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Free-Form Entry

0 4
C54336 Acute Concussion Evaluation (ACE) ? Impact location anatomic site ACEImpactLocationAnatSite Anatomic site of impact injury as related to the Acute Concussion Evaluation (ACE). Anatomic site of impact injury as related to the Acute Concussion Evaluation (ACE). Location of Impact: Frontal;Indirect Force;Left Parietal;Left Temporal;Neck;Occipital;Right Parietal;Right Temporal Frontal;Indirect Force;Left Parietal;Left Temporal;Neck;Occipital;Right Parietal;Right Temporal Alphanumeric Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Adult;Pediatric Supplemental 1.00 2017-02-27 20:16:54.0 Acute Concussion Evaluation (ACE) Cognitive Assessment Outcomes and End Points

Multiple Pre-Defined Values Selected

CSV