The Attorney Guide to Concussion and TBI Documentation
Head injuries are often the least documented part of a crash file. This guide explains how standardized testing and physician-reviewed reports fit into a case record.
Who this is for: Written for Florida personal injury attorneys, paralegals and case managers handling clients with possible concussion or TBI.
Key takeaways
- Concussion symptoms are often under-recorded in early medical visits.
- Good intake questions surface symptoms clients may not mention.
- Testing is ordered through the client's treating provider.
- Physician-reviewed diagnostic reports document findings; they do not predict outcomes.
- Braintree does not weigh in on claim worth or legal strategy.
Why head injuries are under-documented
After a crash, early visits tend to focus on visible injuries and pain. Clients may not connect fogginess, sleep changes or irritability to the collision, and they may not mention them. Without a dated record, those symptoms are hard to describe later.
A dated, standardized record is clearer than memory months later.
Intake and timing
Ask clients specific questions about headaches, memory, concentration, light or noise sensitivity, balance and mood, and when each began. If symptoms persist, the client can ask their treating provider whether standardized testing is appropriate. Testing is done at the provider's office and typically takes 30 to 60 minutes.
Start here, then go deeper: The Provider Guide, TBI Diagnostics Explained, How mobile testing works and all concussion education articles.
What the report does and does not do
The physician-reviewed diagnostic report describes standardized findings and goes to the treating provider. It documents what was measured. It does not assign cause, put a value on a claim or predict outcomes. Reports typically return within 48 hours, or 7 to 10 days when labs are included.
Articles in this guide
- Intake Questions That Surface Hidden Head Injuries in PI Clients
- Standardized vs. Subjective Findings in Concussion Cases
- Does Timing Matter for TBI Testing in a PI Case?
- How Attorneys Can Prepare Clients for Concussion Testing
- Head Injury Documentation Attorneys Review Before a Demand
- Attorney Briefing: 15-Minute Overview
- Attorney Resource Center
- FAQ for Personal Injury Attorneys
- Law Firm Onboarding
- Case Coordination & Report Delivery
Emergency warning signs
If a client describes red flags such as a severe or escalating headache, vomiting, weakness or confusion, tell them to call 911 or go to the ER first.
Frequently asked questions
Can an attorney order testing directly?
Testing is coordinated through the client's treating provider, who receives the physician-reviewed diagnostic report.
Will the report say the crash caused the injury?
No. Reports describe standardized findings. Braintree does not offer opinions on cause, claim worth or outcomes.
How do we learn more?
Book a 15-minute call or phone 813-709-3771.
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
- 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)
- CDC: Symptoms of mild TBI and concussion, including danger signs
- CDC: TBI data and research
This guide is educational and is not medical or legal advice. If this is a medical emergency, call 911.