Slip-and-Fall Head Injuries: Documenting a Possible Concussion

Head injuries from slip-and-fall incidents are often under-documented because attention goes to the fracture or sprain.

Common documentation gaps

No mention of the head strike, symptoms recorded late, and no cognitive screening.

What helps

Symptom notes from treating providers made at the time, plus standardized functional testing when indicated.

Our role

We provide diagnostics through the treating provider. We do not give opinions on liability or causation.

Braintree Health Partners provides diagnostics only. We diagnose. You treat.

Advanced diagnostics, better informed cases. Schedule your attorney briefing today. 813-709-3771.

Falls are a common source of head injury

Slipping on a wet floor, tripping on uneven pavement, or falling down stairs can produce a sudden impact to the head, or a whiplash-like jolt even without a direct hit. Unlike car crashes, falls often happen with no witnesses, and the person may get up embarrassed, brush it off, and go home without seeing anyone. Days later, headaches or fogginess begin, and there's no record connecting them to the fall.

Recording the fall itself

Write down where and when it happened, what you slipped or tripped on, how you landed, and whether your head hit the floor, a step, a counter, or another surface. Note whether anyone saw it and how to contact them. If it's safe and appropriate, photograph the area. Report the incident to the property owner or manager as their process requires. Get medical care promptly and describe the fall clearly to the provider.

Symptoms to watch afterward

Headache, dizziness, nausea, neck pain, light sensitivity, trouble concentrating, memory gaps, irritability, and changes in sleep should all be reported. Note when each started. Older adults and people on blood thinners should be evaluated promptly after any fall involving the head.

Why a treating provider's notes matter

Clear clinical notes made soon after the fall, with symptom ratings that are updated over time, create a reliable record of your health. If symptoms continue, your provider can refer you for standardized testing, which adds physician-reviewed findings to that record.

How Braintree helps

Braintree performs mobile testing at your provider's office and sends the physician-reviewed report to the provider. We provide diagnostics only. We don't give opinions about fault, liability, or legal claims. Questions about those should go to an attorney. We diagnose. You treat.

Emergency warning signs

After any fall, go to the ER or call 911 for a worsening headache, repeated vomiting, unusual drowsiness, confusion, slurred speech, weakness, seizures, or clear fluid from the nose or ears.

Common mistakes after a fall

The most common mistake is waiting. People assume a headache will pass, skip the doctor, and only seek care when symptoms disrupt their work weeks later. Another is describing the fall vaguely ("I slipped") without saying that the head struck something. A third is not following up when new symptoms appear. Getting seen promptly, describing the impact accurately, and reporting changes as they happen all lead to better care. If you were alone when you fell and aren't sure whether you hit your head, say exactly that. An honest "I don't remember" is useful clinical information.

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