Traumatic brain injury (TBI) is a serious condition that can have life-altering effects on those who suffer from it. In Ohio, proving TBI in a court of law is crucial for victims to receive just compensation for their injuries. However, doing so requires comprehensive medical documentation from the onset of injury through treatment and recovery. This article will examine why proper medical documentation is vital for proving TBI in Ohio’s courts.
Understanding TBI
A TBI occurs when an external force traumatically injures the brain. The injury can be classified as mild, moderate or severe, depending on factors such as length of unconsciousness, post-traumatic amnesia, and abnormalities evident on neurological imaging. Common causes of TBI include falls, vehicle accidents, sports injuries, assaults, and explosions.
Symptoms of TBI can be wide-ranging, from physical effects like headaches, dizziness, nausea, and fatigue, to cognitive problems with memory, concentration, speech, and more. TBI can also cause emotional and behavioral issues such as depression, anxiety, impulsivity, and aggression. These issues may be temporary or persist for months or years post-injury. Patients may also experience sensory problems such as sensitivity to light or sound.
The Importance of Documenting TBI
Given the complex nature of TBI, comprehensive medical documentation is crucial for accurately recording and tracking a patient’s injuries, treatment, and progress. Thorough records aid physicians in providing appropriate care while also serving as evidence in potential legal claims.
In personal injury cases in Ohio, plaintiffs must prove that the defendant’s negligence directly caused their injuries and damages. Documentation clearly demonstrating the plaintiff’s diagnosis, symptoms, treatments, and recovery timeline helps verify the presence and extent of their TBI.
Specific types of medical documentation that are vital in TBI cases include:
- Emergency Room and Hospital Records – Notes and test results from ER visits immediately following the initial injury provide baseline details on symptoms, neurological exam results, imaging study findings, and early diagnoses.
- Specialist Records – Follow-up visits with neurologists, neuropsychologists, physical medicine specialists, and rehab physicians track continued care and lingering effects of TBI over time.
- Therapy Notes – Documentation from speech, physical, occupational, and cognitive therapies capture the plaintiff’s functional deficits and progress through treatment.
- Imaging Reports – MRI, CT and PET scan results may reveal brain abnormalities like bleeding, swelling or damaged tissue caused by traumatic forces.
- Neuropsychological Testing – Formal cognitive assessments identify specific thinking, memory, attention, language, and executive functioning impairments stemming from TBI.
- Prescription Records – Ongoing medications needed to manage TBI symptoms further validate the plaintiff’s injuries and impairment.
Key Medical Documentation Tips
To ensure medical records adequately support a TBI claim, plaintiffs should follow these best practices:
- Seek prompt emergency care – Be evaluated in the ER as soon as possible after a head injury for proper diagnosis and early records.
- Attend all follow-up appointments – Consistently going to scheduled neurology, therapy, counseling, and other visits demonstrates diligent care.
- Comply with testing and imaging – Complete recommended neurological/cognitive assessments and scans so abnormalities are caught early.
- Report all symptoms – Fully disclose headache, cognition, emotional, sleep, balance and any other issues at appointments. Provide specific examples and details wherever possible.
- Keep a detailed journal – Track symptoms, triggers, functioning challenges, and recovery on a daily basis. Note times, durations and severity.
- Ask doctors to document discussions – Have physicians record recommended treatments, medications, restrictions, referrals and prognoses in visit notes.
- Request copies of medical records – Obtain full copies to review accuracy and thoroughly provide to your attorney.
- Be truthful – Honesty about pre-existing conditions and symptoms is crucial for accurate documentation.
- Follow up on referrals – If you have been advised to see additional specialists, be sure to schedule and attend those appointments.
- Highlight gaps in care – If you are unable to access recommended treatment/therapy, have doctors note those lapses.
Consulting a TBI Attorney
The experienced personal injury attorneys at Monge & Associates are committed advocates for TBI victims in Ohio. Our lawyers fully understand the complexities of documenting traumatic brain injuries to prove causation and damages in court. We have successfully handled numerous TBI cases, skillfully demonstrating the evidence needed to recover fair compensation for our deserving clients.
If you have suffered a traumatic brain injury due to another’s negligence in Ohio, contact Monge & Associates today for a free consultation at (888) 477-0597. With 32 offices in 19 states, including Ohio, Georgia, and Tennessee, our attorneys have the resources and expertise to handle brain injury cases across multiple jurisdictions. Let us review your case details and develop a comprehensive legal strategy to fight for you in Ohio’s courts. Your recovery and wellbeing are our top priorities.