Head Injury Documentation Attorneys Review Before a Demand

Who this is for: Written for personal injury attorneys and paralegals reviewing head-injury records before a demand goes out.

A note on scope

This article is for attorneys who want to understand how clinical documentation of a head injury is typically organized. Braintree is a diagnostics company, not a law firm. We do not give legal advice, and nothing here suggests how to value a claim or what any document will achieve. Demand strategy belongs to counsel.

Reading the records together gives the most complete picture.

What clinical records generally contain

A head-injury record often includes emergency department and urgent care notes, imaging reports, treating provider intake and progress notes with symptom histories, functional testing reports with physician interpretation, specialist evaluations and records of any work or activity restrictions. Each serves a different clinical purpose. Read together, they give the most complete picture.

Organizing records chronologically

Many attorneys build a timeline: date of injury, first medical visit, first mention of each symptom, dates of testing and specialist visits, and changes in restrictions. Gaps in care and late-appearing symptoms become easy to see, and so do symptoms that were mentioned but never evaluated. That helps counsel ask the right questions of providers through proper channels.

Related in this series: Sample Report Walkthrough (Synthetic Example), Standardized vs. Subjective Findings in Concussion Cases and Attorney Briefing: 15-Minute Overview. For the full overview, start with our guide, Attorney Guide to TBI Documentation.

Reading a functional testing report

A Braintree report states which tests were performed and when, presents results relative to reference data where applicable and includes the physician's interpretation, along with any suggested further evaluations. It describes clinical findings on the test date. It does not assess causation, permanency, damages or admissibility, and should not be described as doing so.

Gaps in follow-up often reflect obstacles such as transportation, cost or cognitive difficulty with scheduling.

Avoiding common mistakes

Do not summarize a report in ways that change its meaning. Quote or attach the physician's interpretation accurately. Do not ask diagnostic providers to add legal conclusions. If clinical questions remain, raise them with the client's treating provider.

Requesting records properly

Request records with a valid client authorization through each provider's normal release process, and ask for complete records instead of selected pages so the clinical picture is not distorted. If a report mentions suggested specialist evaluations, check whether the client followed up. Gaps often reflect obstacles such as transportation, cost or cognitive difficulty with scheduling, and those are worth discussing with the client.

Supporting the client's care

For a client with ongoing symptoms, the most important thing is appropriate care. Make sure they have a treating provider and follow that provider's guidance. A 15-minute briefing explains how Braintree works with treating providers and how reports are structured. Call 813-709-3771.

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