The Gateway

Documenting traumatic brain injury (TBI) in a patient’s electronic medical record (EMR) is important for the Soldier’s continuum of care. There are forms and applications already available within the MC4 system to assist health care providers in documenting this information.

• In AHLTA-Mobile, the MACE Form is available to users for evaluation of blast injuries and potential head injuries. This evaluation helps with the diagnosis of mTBI.

• AHLTA-T offers medical providers the MACE v2010 AIM form and the mTBI AIM form. When documenting TBI symptoms in AHLTA-T, specific diagnostic codes should be used as required by the Central Command Fragmentary Order on concussion and mTBI management and tracking.

  These AIM forms help organize the assessment and evaluation of potential head injuries. However, they do not offer the recommendations and calculation like the embedded MACE form in AHLTA-Mobile or on paper. In the future the MACE evaluation will be imbedded in AHLTA-T.