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How To Accurately Document Traumatic Brain Injuries

Your medical records determine whether cases are won or lost! Since chiropractors and ER doctors are the first doctors to see a patient after an accident, the initial complaints are even more important. Of the thousands of personal injury cases I have handled over the years, more often than not, the initial medical records fail to accurately capture all of the patients injuries and complaints. Emergency room records are the worst because they are trained to treat the patient’s “primary complaint” and often leave secondary complaints out of the records all together. This creates a significant problem for personal injury attorneys because insurance defense lawyers argue that injuries not captured in the initial visit never occurred.

Chiropractors are better at documenting the patient’s complaints during the initial visit because they are trained to treat the whole body, and not just the patient’s primary complaint. Over the years, however, I have noticed that chiropractors seldom discuss or identify traumatic brain injuries (TBI). Unlike a radiculopathy that is readily detectable with a straight leg raise, or a loss of lordosis that can be seen on imaging, mild and moderate traumatic brain injuries are hard to detect. Since most brain injuries are not detectable by imaging, an accurate diagnosis requires the doctor to understand their patient’s cognitive functioning before the accident to understand the patient’s impairments after the accident.

Years ago I had a client who was injured at a gym. He was pulling 250 pounds on a lat machine when a defective rubber belt broke causing the metal bar to smash into the top of his head. He was rushed by ambulance to the emergency room. He then treated with a chiropractor, and later, saw a neurologist who diagnosed him with a traumatic brain injury. Because the chiropractor’s report did not contain complaints related to a brain injury, the insurance defense lawyer used the report to argue that the patient was fabricating his traumatic brain injury.

When I first met with the patient, he seemed normal. I asked him to wait outside my office so I can ask his wife to describe his injuries. The wife started to cry. She told me that her husband used to laugh, make jokes, talk a “mile a minute,” and take the family to restaurants and local trips every weekend. She said after the accident, her husband does not leave the house. He just sits on the couch and watches TV. Her husband coached a kids soccer team for 16 years. After the accident he was fired because he lost his temper too many times and would violently yell at the kids and their parents. From the impact to his head, her husband had trouble making decisions, which made him frustrated, which made him furious. To someone who did not know the patient before his injury (like me and the treating chiropractor) the patient seemed normal, but to his wife, he was a broken man. Because I consulted with his wife, I understood who my client was before his injury, which gave me the background I needed to understand how the traumatic brain injury affected him.

The best way to stop insurance companies from denying your patient’s injuries, is to accurately and honestly document them in your medical records. Because too many doctors (mainly chiropractors and emergency room physicians) fail to accurately diagnose traumatic brain injuries, I sat down with our consulting neurologist to identify the most common traumatic brain injury symptoms and the questions to identify them.

Questions For Identifying Traumatic Brain Injuries:

  1. Did they lose consciousness, blackout, or have an altered state of mind?

    Most neurologists agree that to have suffered a traumatic brain injury, the patient must have lost consciousness, OR, had some degree of an altered state of mind. Since many patients do not know that they were unconscious, especially when it was momentary, I usually ask them what is their first memory following the impact. A lot of times they tell me they remember the police officer knocking on their window – they don’t recall their airbag exploding, their car coming to a stop, sitting in their car for 5 minutes – all of which occurred before the police arrived.

    A good way to determine altered state of mind is to ask the patient what they did immediately after the impact (look too see if they were alert or disoriented). f the patient tells you that they immediately jumped out of the car to check on others, or took control of the situation and called 911, then likely, no altered state of mind. However, when patients tell me that they did not know what happed, or that they sat in their car for 5 minutes before they figured it out, then this is a red flag for an altered state of mind. (You can also look at the ambulance report to see if there was a reduced score on the Glasgow Coma Scale, which of course, is the most common scoring system to describe the level of consciousness in a person following a traumatic brain injury. A score of 15 means there was no altered state of mind. Anything less points to a brain injury – You can also perform this test yourself if the patient came to see you on the day of the accident).

  2. Do they have amnesia to events?

    Neurologists also agree that a patient with a traumatic brain injury will have some memory loss. I had one client tell me that all she remembered from the day of the accident was standing at an ATM machine and later waking up in the emergency room. The interesting thing is that she was at the ATM six hours before the accident. Usually, the amnesia is not this pronounced. Most of the time patients forget important details like how they got to the hospital or whether the police came to the scene. If they have any amnesia, make sure to document it.

  3. Do they have a hard time finding words to use?

    Loss of verbal expression is controlled by the frontal lobe. The frontal lobe can be injured in rear-end and front-end crashes when the brain impacts the inside of the skull in a coup-contrecoup type injury. I suspect this type of a traumatic brain injury anytime a patient is in my office and they have trouble finding the right words to use when telling me how the accident happened. The patient will usually get embarrassed, unable to produce words that they typically use. If this occurs, its important to document.

  4. Do they have mood swings?

    Most of my traumatic brain injury clients have mood swings. They usually report going in and out of depression or aggression several times during the course of a week. This is a good question to ask their loved ones as they are more perceptive to the mood changes.

  5. Do they have short-term memory problems?

    Most of my traumatic brain injury clients have mood swings. They usually report going in and out of depression or aggression several times during the course of a week. This is a good question to ask their loved ones as they are more perceptive to the mood changes.

  6. Do they have problems with their vision after the accident?

    Patients who have more than just mild brain injuries are the ones who usually report issues with vision. These issues include having a hard time locating objects, partially losing vision in one eye, having a hard time seeing things in movement. My clients who report vision loss usually have a lot of other cognitive impairments so its easier for the doctor to diagnose the TBI.

  7. Do they have difficulty concentrating or paying attention?

    Since concentration is controlled by the brain, I always pay close attention to whether my client is having a hard time at the initial consultation. Usually my clients they tend to “zone out” or give me an empty stare. When I see this, I ask a family member if the client was like this before the accident.

  8. Do they have sensitively to light?

    Ask if they wear sunglasses more often since the accident or whether they prefer darker rooms. Many times, after I turn off my office lights, I notice that my clients feel considerably better. If you notice this, document it in your records.

  9. Do they have headaches?

    It is important to ask about the frequency of headaches they had before the accident to set a baseline to understand whether their headaches have actually increased since the accident.

  10. Are they having tinnitus?

    My clients who have a ringing in their ears will usually have it closer in time to the impact. It is important to differentiate between temporary tinnitus, from the noise of the exploding airbag, for example, and long term tinnitus from brain damage. Referral to an ENT specialist may be necessary to differentiate, especially if the tinnitus continues.

  11. Are they sleeping normally since the accident?

    Many of my TBI clients report sleep disturbances. Its important to accurately document these incase they do not resolve with time. Fortunately, most do.

  12. Do they have a hard time making decisions?

    Too many of my clients have a hard time with decisions after a brain injury. This is a questions for the family member and not necessarily the patient. It is very important to document this in your report.

The neurologist who consult on my personal injury cases tell me that the majority of traumatic brain injuries resolve within a year. This is great news. For those less fortunate people who have long lasting traumatic brain injuries, however, it is important to accurately document the brain injury early so subsequent doctors can have the information they need to provide future care. By accurately documenting all the complaints soon after the accident, insurance defense lawyers will not be able to deny care, treatment and compensation to honest people.

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