How to Document Evidence for a Brain Injury Claim

How to Document Evidence for a Brain Injury Claim

A traumatic brain injury (TBI) is one of the most complex injuries to document in the Texas legal system. Unlike a visible fracture or a herniated disc, a brain injury is invisible to the naked eye and can produce subjective symptoms like chronic brain fog, severe headaches, memory loss, and personality changes.

Insurance companies capitalize on this invisibility. They will argue that without concrete proof on a standard MRI or CT scan, your symptoms are exaggerated, pre-existing, or psychosomatic.

At DFW Injury Lawyers, we know that proving a TBI requires a meticulous, multi-layered strategy that goes far beyond the emergency room. It demands an immediate, dedicated effort to document medical, financial, and personal evidence that links the accident directly to your cognitive and functional decline.

Our guide outlines the critical steps you must take right now to build an undeniable case and attempt to secure the maximum compensation you need for a lifetime of care.

Call (972) 440-2320 to discuss your TBI case with a dedicated traumatic brain injury lawyer.

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Key Takeaways: Documenting a Brain Injury Claim

• Report All Symptoms Immediately: Document any initial confusion, disorientation, or headache to establish the critical link between the accident and the injury.
• Go Beyond Standard Imaging: Since TBI damage is often microscopic, your claim hinges on objective, advanced testing: Neuropsychological Testing (to quantify cognitive deficits) and DTI/fMRI (to prove structural damage to white matter).
• Keep a Detailed Symptom Journal: This is vital for proving non-economic damages. Record daily entries detailing cognitive incidents (memory lapse, brain fog), emotional changes, and activities you can no longer perform.
• Collateral Witnesses are Key: Obtain testimony from spouses, family, and colleagues to prove the functional difference between the "pre-accident you" and the "post-accident you."
• Invest in Financial Experts: For lifetime injuries, use a Forensic Economist to calculate lost future earning capacity and a Life Care Planner to project all future medical and care costs. Never settle before these reports are complete.

Phase 1: Immediate Post-Accident Documentation

The evidence collected in the first three days is foundational to proving causation, the direct link between the defendant’s negligence and your TBI. Do not rely solely on police or EMS reports.

1. The Scene and Liability Evidence

Even if you only suspect a concussion, documentation of the crash scene is crucial for establishing the severity of the impact.

• Photos and Video: If possible, take pictures or have a family member take pictures of:
  • The property damage to the vehicles.
  • Skid marks, debris, and the surrounding environment.
  • Any traffic signals, stop signs, or obstructions that prove the defendant’s liability (running a red light, failure to yield).
• Witness Information: Collect the names, phone numbers, and emails of anyone who witnessed the accident or your immediate aftermath. Crucially, ask witnesses if they heard you complain of dizziness or confusion right after the impact.
• The Police Report: Obtain a copy. While not always accurate, it documents the initial facts, location, and the citations issued to the at-fault driver.

2. Immediate Medical Assessment

The first notes documented by paramedics and emergency room staff are vital because they establish the immediate neurological impact.

• Do Not Say "I’m Fine": Due to adrenaline, you may feel lucid. If you experienced any blow to the head, loss of consciousness (even briefly), confusion, disorientation, or nausea, report every single symptom to the paramedics and ER doctor.
• The Glasgow Coma Scale (GCS): This is the standardized scoring system used by medical professionals to assess a patient's consciousness level.
  • Documentation Focus: Ensure the medical records reflect the initial GCS score, even if it’s a high score. Any report of confusion, disorientation, or amnesia is critical evidence of a TBI.
• Demand a CT Scan: While CT scans rarely show mTBI/concussion damage, they are necessary to rule out severe issues like hematomas (brain bleeds). The mere fact that a CT was required documents the severity of the trauma.

Phase 2: Comprehensive Medical Documentation

This is the most challenging phase. To defeat the insurance company’s claim that your TBI symptoms are subjective, your attorney must guide you through objective diagnostic testing.

3. Seek Specialized TBI Medical Care

A regular primary care physician is not equipped to manage chronic TBI symptoms or generate the necessary legal evidence.

• Referral Chain: Request immediate referrals to TBI specialists:
  • Neurologist: For managing chronic physical symptoms like headaches, dizziness, and sleep disturbance.
  • Neuropsychologist: This specialized doctor performs the objective cognitive testing required for legal proof.
  • Ophthalmologist/Vestibular Therapist: Many TBI symptoms involve vision tracking or balance issues, which must be documented by specialists.
• Adherence to Treatment: Follow every recommendation. Missed appointments, failure to attend physical therapy, or gaps in your treatment history will be used by the defense to argue your injuries are not serious.

4. Objective Diagnostic Testing

Since traditional CT/MRI scans often come back "normal," your claim hinges on the following advanced, objective tests:

A. Neuropsychological Testing

• Purpose: These are extensive, standardized tests that objectively measure specific functions like memory, attention, processing speed, and executive function.
• Legal Value: The resulting report quantifies the functional deficits caused by the TBI. It transforms a subjective complaint ("I can't remember things") into an objective medical finding (e.g., "The patient exhibits a 40% reduction in auditory working memory, placing them in the 5th percentile for their age.")
• Consistency: The neuropsychologist will assess your effort and consistency. A valid, effortful performance is essential to confirm the results are a true reflection of injury, not malingering.

B. Advanced Brain Imaging

• Diffusion Tensor Imaging (DTI): This advanced MRI technique maps the water diffusion along the brain's white matter tracts (axons). DAI (Diffuse Axonal Injury), the widespread tearing of these fibers, is the primary cause of long-term cognitive impairment in concussions but is invisible on standard MRIs. DTI can reveal this crucial evidence.
• Functional MRI (fMRI): This measures brain activity by detecting changes in blood flow. It can show which areas of the brain are functioning abnormally during cognitive tasks.
• Why It Matters: Presenting DTI or fMRI evidence can successfully defeat the defense’s entire argument that "the MRI is clear, therefore there is no injury."

5. Final Medical Documentation (MMI and Impairment Rating)

Before your attorney can submit a settlement demand, your doctor must establish two key things:

• Maximum Medical Improvement (MMI): The point at which your condition has stabilized and is unlikely to improve further. You must wait until this point to ensure all future costs are calculated.
• Permanent Impairment Rating: A doctor issues a formal percentage rating reflecting your permanent loss of function, which is critical for valuing lost future earning capacity.

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Phase 3: Lifestyle and Functional Documentation (Proving Non-Economic Damages)

TBIs devastate personal life, leading to non-economic damages like pain, suffering, and mental anguish. This evidence proves how the TBI changed the person you were.

6. The TBI Symptom Journal

This is the most powerful tool for documenting the subjective, daily reality of living with a TBI.

• Daily Entries: Record every entry as soon as it happens, focusing on specific details:
  • Headaches: Intensity (1-10), duration, location, and what triggered them.
  • Cognitive Incidents: Detail specific instances of memory loss, difficulty concentrating, or word-finding issues.
  • Emotional Changes: Document outbursts of anger, extreme fatigue, anxiety, or uncharacteristic emotional swings.
• Before/After Comparison: Explicitly note activities you can no longer perform (e.g., "Used to read 3 books a month; now I can only manage one page before the dizziness starts.")

7. Collateral Witness Testimony

Your own journal is strong, but testimony from those closest to you is irrefutable evidence of personality and functional change.

• Spouse/Partner: Document the impact on your relationship (loss of intimacy, increased irritability, reliance on the partner for basic tasks).
• Family and Friends: Document how the TBI has affected social life (inability to tolerate loud places, cancellation of activities, withdrawal).
• Colleagues/Supervisors: Document changes in your professional capacity, increased errors, difficulty managing complexity, or needing longer to complete tasks. Your attorney will use these people to testify to the functional difference between the "pre-accident you" and the "post-accident you."

Phase 4: Financial Documentation (Valuing Lifetime Loss)

TBI damages often exceed standard policy limits because they are lifelong injuries. Calculating the future financial need requires help.

8. Document Lost Wages and Impaired Earning Capacity

• Lost Wages: Collect payroll stubs, tax returns, and employer statements to prove the time you missed from work.
• Impaired Earning Capacity: If the TBI forces you to take a lower-paying job, retire early, or prevents you from advancing, your attorney will hire a forensic economist. This expert projects the net present value of your total lost income over your expected working life, providing a massive, quantifiable damage figure.

9. Life Care Planning (Severe TBI)

In cases of a TBI that requires long-term assistance, a life care planner is essential.

• Purpose: This expert meticulously reviews all your medical records and determines every future need for the rest of your life: specialized equipment, medications, cognitive therapy sessions, home health aides, necessary home renovations (ramps, stair lifts), and specialized transportation.
• Legal Value: The Life Care Plan provides an itemized, report of future expenses, which can easily total millions of dollars, justifying the high valuation of your claim.

Why We Excel at TBI Documentation

Proving an invisible injury like a TBI is fundamentally different from proving a broken bone. It requires an attorney who knows the medical science and the specific legal tools needed to overcome insurance defense bias.

Immediate Medical Referrals and Network

We don’t wait. The moment you become our client, we connect you with the top neurologists and neuropsychologists who specialize in TBI and are experienced in courtroom testimony. This ensures your medical records are legally defensible and objective proof (like DTI) is ordered immediately.

Evidence Investment

We front the substantial costs required for advanced diagnostics, neuropsychological evaluations, forensic economists, and life care planners. We view this investment in evidence as non-negotiable for your case.

Comprehensive Lifetime Valuation

We go beyond past bills. We understand how to utilize the TBI symptom journal and collateral testimony to justify massive non-economic damage awards, while our financial experts quantify every single dollar of lost earning capacity and future care, ensuring your settlement covers you for life.

Trial Readiness

Insurance companies know which firms only settle and which firms are prepared to fight a TBI case in front of a Texas jury. Our reputation for thorough documentation and trial readiness provides the necessary leverage to secure maximum value at the negotiating table, often avoiding the lengthy timeline of a full trial.

Start Documenting Now

If you are struggling with the debilitating and often frustrating effects of a TBI after an accident, the biggest mistake you can make is waiting. Remember the core principles: document everything, seek specialized care, and never settle early. 

The crucial evidence, from your daily symptom journal to objective DTI results, is perishable, and the insurance company is already working diligently to minimize your claim. A TBI is not "just a headache"—it is a life-altering injury with devastating financial and personal costs. 

We, as DFW Injury Lawyers, stand ready to transform your subjective suffering into a legally sound claim. We are your advocates for the long term, investing in the medical specialists and financial experts necessary to secure the resources required for a lifetime of care.

Protect your health and your financial future by immediately partnering with an experienced personal injury lawyer prepared to prove the invisible. Contact us today for a free, confidential case evaluation. We will immediately implement a comprehensive strategy tailored to your TBI case, ensuring your voice is heard and your future is protected.

Call (972) 440-2320 or fill out our online form now.

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