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Diagnosis information
Key features, specifiers, differential considerations, and documentation support in one open, scan-friendly view. Full DSM-5-TR criteria are not included in this record.
The full DSM-5-TR criteria are not included in this record. Everything the record does hold is shown below. Check DSM-5-TR before recording the diagnosis.
Key feature A
Criteria met for major or mild NCD
Key feature B
Evidence of TBI: loss of consciousness; post-traumatic amnesia; disorientation/confusion; neurological signs — occurring in impact context
Key feature C
NCD presents immediately after TBI or immediately after regaining consciousness; persists beyond acute post-injury period
Key feature D
Disturbance not better explained by another condition
Record each key feature against your assessment. The note is built from what you mark, and anything you leave alone is written out as not assessed. This record does not include the full DSM-5-TR criteria, so the note states that it was built from a key feature summary.
Tick only those you actively considered and ruled out.
Mark at least one key feature to build the note.
Plain characters only, so the text pastes cleanly into a record. This is a documentation aid and not a substitute for diagnostic reasoning or local documentation requirements.
Clinical reference aid only. Confirm the full assessment, exclusions, cultural context, and current diagnostic standard.
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