Sports medicine has an unusual documentation burden for a specialty with short visits.

The RealitySix steps, one written clearance

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The Problem

The protocol lives in a paragraph.

Steps described in prose across several notes, so nobody can see which athletes are mid-protocol, and the clearance letter is retyped each time.

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The Solution

Steps as dated rows, clearance as an output.

Record each stage with its date and symptom status, and generate the written clearance from that record rather than composing it separately.

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The Resolution

A defensible record and a faster letter.

The progression is visible, the clearance matches it exactly, and a query answers who is where this week.

The graduated protocol, step by step

CDC’s progression is six steps and it is worth having them exactly rather than approximately, because the template should mirror them.

Step one is a return to regular activities such as school, with a green light from the healthcare provider to begin the progression. Step two is light aerobic activity only, described as about five to ten minutes on an exercise bike, walking or light jogging, with no weight lifting. Step three is moderate activity with body or head movement — moderate jogging, brief running, moderate-intensity stationary biking, moderate-intensity weightlifting at less time or less weight than usual. Step four is heavy non-contact activity: sprinting, high-intensity stationary biking, a regular weightlifting routine, non-contact sport-specific drills. Step five is a return to practice and full contact where appropriate for the sport, in controlled practice. Step six is competition.

The guidance adds the rule that makes the record matter: if symptoms return, the athlete stops and the medical provider is contacted, and after more rest and no symptoms the athlete restarts at the previous step. A protocol that can go backwards is a protocol that needs dated rows rather than a narrative.

Symptom tracking between the steps

The progression is driven by symptoms, which means symptom status at each step is the clinical evidence for advancing.

Capture it as a structured value at each stage rather than as a description. What the specific instrument is matters less than that the same one is used each time, because the point is comparison across steps rather than an absolute score. A practice that changes instrument mid-protocol has a record that cannot show progression.

The reason this deserves a field rather than a sentence is the step-back rule. If an athlete regresses, the record should show which step, on what date, with what symptom status — and that is a query, not a re-reading. Getting the instrument and its placement right is ordinary template development work.

Written clearance and who may give it

Here the record stops being clinical and becomes legal, and the requirements are set by state rather than federal law.

New Jersey’s statute, in force since the 2011–12 school year, requires that a student-athlete removed from competition or practice cannot return until evaluated by a physician or other licensed healthcare provider trained in the evaluation and management of concussions, and until they receive written clearance from a physician trained in the evaluation and management of concussions and have completed the district’s graduated return-to-play protocol.

Note the structure: evaluation by one category of provider, written clearance from a physician, and completion of a protocol belonging to the district rather than to you. All three have to be true, and the record should evidence all three. Confirm the current requirement with your own counsel or the state rather than from any summary including this one — these statutes are amended.

State law varies, and the template has to know it

A practice seeing athletes from more than one state is operating under more than one rule, and the differences are not cosmetic.

Pennsylvania’s law, effective July 2012, requires removal from play on signs or symptoms and written clearance by an appropriate medical professional, with three categories defined: a licensed physician trained in concussion evaluation and management; a licensed or certified healthcare professional so trained and designated by an appropriate licensed physician; and a licensed psychologist with neuropsychological training or postdoctoral training in neuropsychology with specific concussion training.

North Carolina’s Gfeller-Waller Concussion Awareness Act, signed in June 2011, is organised around three areas: education, emergency action and post-concussion protocol implementation, and clearance for return to play or practice, and states that each school should maintain documentation of compliance.

CDC’s clinical guidance makes the same point to clinicians directly: before the season starts, learn the laws or policies of the state, league or governing body. A template that hard-codes one state’s requirement will be wrong for the athlete who crosses a line to play.

The athlete record across a season

One more structural point. A concussion is not always a single episode, and the second is more consequential than the first.

NINDS describes a concussion as a type of mild traumatic brain injury that may take minutes to several months to heal, and notes that a second concussion closely following the first — the second hit phenomenon — can lead to permanent damage or even death in some cases. It adds that children and teens with a sports-related concussion should stop playing immediately and return only after approval by a concussion specialist.

For the record, that means prior concussions have to be visible at the point of assessment rather than discoverable. A header field showing prior episodes with dates does more clinical work than any amount of narrative history, and it is a small build.

• Build the six steps as dated rows. With a symptom status at each and the ability to step back.
• Generate the clearance from the record. Not as a separately composed letter.
• Make the applicable state a field. Multi-state practices need it.
• Surface prior concussions in the header. Visible, not discoverable.

Qventive provides return to play documentation EHR help for medical practices across New Jersey, usually as part of our sports medicine EHR and IT support and a broader sports medicine practice management engagement.

Because clearance documents go to schools and families rather than staying in the chart, the release path belongs in your HIPAA risk analysis, and it is usually the part nobody has written down.

For scale: CDC reports approximately 214,110 traumatic brain injury-related hospitalisations in 2020 and 68,663 TBI-related deaths in 2023, drawn from the national inpatient sample and its injury statistics system. Most sports concussions never reach a hospital, which is precisely why the outpatient record is the one that has to hold up.

Return to play records: common questions