What Paperwork Is Needed to Refer a Patient for TBI Testing
Referring a patient for TBI testing should take minutes. The few extra details you add to the form decide how specific, and how useful, the physician-reviewed report will be.
Who this is for: Written for front-desk staff and providers filling out a TBI testing referral who want it complete the first time.
Key takeaways
- The physician interprets results against the history and symptoms on your referral. Thin referrals make for less specific reports.
- Include mechanism of injury, head strike, loss of consciousness or memory gap, ER visit and imaging, rated symptoms, history and medications.
- Attach relevant notes and ER paperwork. You do not need the whole chart.
- Use the secure referral form. Never send protected health information by unencrypted email or text.
- Specific, dated, rated symptom lines help the physician most.
Why paperwork affects quality
A referral form looks like a formality. It is not. The reviewing physician interprets test results against the patient's history and symptoms, so when a referral says only "concussion test, MVA," the physician has little context and the report may be less specific. A complete referral takes a few extra minutes and pays off in a clearer report.
A complete referral takes a few extra minutes and pays off in a clearer report.
What to include
- Patient's full name, date of birth, phone number and preferred language
- Date of injury and mechanism: rear-end, T-bone, rollover, fall, struck by an object
- Whether the head struck anything, and any loss of consciousness or memory gap
- Whether the patient was seen in an emergency department and had imaging
- Current symptoms with severity ratings, and how they have changed since intake
- Relevant history: prior concussions, migraines, learning differences, neurological or psychiatric conditions, current medications
- The treating provider's details
Attach what you have
If available, attach intake notes, recent progress notes with symptom ratings and ER discharge paperwork or imaging reports. You do not need to send the whole chart, only what is relevant.
Related in this series: Referral Guide for Providers (PDF + Page), When to Refer for Concussion Testing: A Provider Checklist and How a Mobile Testing Day Works at Your Practice. For the full overview, start with our guide, Provider Guide to TBI Testing.
A sample symptom line
"Headache 6/10 daily, worse with screens; dizziness on rising 3/10; loses train of thought at work several times a day; sleeps about 5 hours, frequent waking. Intake 3 weeks ago: headache 7/10, others not reported." Specific, dated and rated, this is the level of detail that helps the physician most, and it lets your own team see at a glance whether the patient is improving.
Specific, dated and rated: this is the level of detail that helps the physician most.
Privacy and secure transmission
Send referrals through the secure referral form at /referral or by the method Braintree's team provides. Do not send protected health information by unencrypted email or text. Our team explains secure options during onboarding.
After you submit
Our team confirms receipt, contacts your office to schedule a testing day and tells you if anything is missing. The physician-reviewed diagnostic report comes back to you, the treating provider, typically within 48 hours, or typically 7 to 10 days when labs are included.
Common gaps to avoid
The most frequent gaps are a missing mechanism of injury, symptom lists without ratings, no mention of prior history and outdated patient contact details. A quick check before sending avoids delays. Need a template? We provide a referral checklist for your staff. Call 813-709-3771.
Frequently asked questions
What's the most common referral gap?
Missing date and mechanism of injury, or symptoms listed without ratings.
Should we attach prior records?
Attach what you have, such as ER notes or imaging reports. It helps the physician interpret results.
How do we send it securely?
Use the secure channel provided during onboarding. Don't send patient details by regular email.
We diagnose. You treat.
Mobile, physician-reviewed concussion and TBI diagnostics for Florida providers and their accident patients. Reports go to the treating provider, who decides care.
Book a 15-minute callRefer a patientOr call 813-709-3771
Sources
- CDC: Symptoms of mild TBI and concussion, including danger signs
- Seabury SA et al. Follow-up care after ED presentation for mild TBI and concussion: results from the TRACK-TBI study. JAMA Netw Open. 2018 (NIH PubMed)
- TRACK-TBI (Transforming Research and Clinical Knowledge in TBI), UCSF
This article is educational and is not medical or legal advice. If this is a medical emergency, call 911.