A later account of memory, concentration, mood, sleep, communication, or daily function is easier to understand when it can be compared with a documented pre-injury baseline. A baseline is not an assumption that a person had no prior condition. It is a dated, source-specific description of how the person functioned before the event.

A baseline should identify the activity, time period, information source, observed ability or limitation, record location, and any uncertainty before it is compared with post-event evidence.

Define the comparison period and the question

Choose a period that is close enough to the event to be useful while also capturing ordinary variation. State the exact question: memory for appointments, ability to follow multi-step instructions, work pace, school performance, driving, household management, emotional regulation, sleep, exercise, social activity, or another identified function. Do not replace a specific question with a general claim that everything changed.

Build the baseline from more than one source

  • Prior primary-care, emergency, neurological, behavioral-health, medication, therapy, vision, hearing, and sleep records when relevant
  • School attendance, grades, accommodations, testing, assignments, disciplinary records, and teacher observations for the period actually at issue
  • Employment duties, schedules, evaluations, productivity measures, attendance, training, accommodations, and supervisor observations
  • Calendar, messages, bills, banking routines, transportation, household tasks, caregiving, exercise, hobbies, community activities, and device records that document ordinary function
  • Direct observations from family members, coworkers, teachers, friends, or others who can identify what they personally saw and when

Use medical records without turning them into a complete life history

The U.S. Department of Health and Human Services explains that an individual generally may inspect, obtain, and request correction of medical and billing records, subject to stated exceptions and limits. Request the relevant providers and date ranges, preserve the original production, and note missing visits, outside records, addenda, and amendment requests. A record created for treatment may not describe every ability that mattered at home, school, or work.

Separate symptoms, function, and diagnosis

The Centers for Disease Control and Prevention identifies thinking, memory, emotional, sleep, and physical symptoms that may occur after mild traumatic brain injury or concussion and notes that some symptoms overlap other health problems. Its TBI and concussion symptom guidance is a useful vocabulary source, but a checklist does not diagnose a particular person or establish what caused a reported change.

Record direct observations with their limits

North Carolina Rule of Evidence 701 limits lay opinions to those rationally based on the witness’s perception and helpful to understanding the testimony or a fact in issue. A useful observation identifies the task, setting, date or period, what the person did before, what the observer personally saw, and what changed. It should not assign a medical diagnosis or claim expertise the observer does not have.

Preserve prior conditions and ordinary variation

  • Earlier injuries, diagnoses, medications, sleep problems, stressors, learning differences, or symptoms that may affect the same function
  • Normal differences between weekdays and weekends, busy and quiet periods, work and vacation, or supervised and independent tasks
  • Source conflicts, incomplete records, changed recollections, missing periods, and facts that do not support the initial assumption
  • Later illnesses, injuries, medication changes, or life events that may complicate the comparison

Create a reproducible comparison table

For each function, list the pre-event source and date, the post-event source and date, the observed difference, competing explanation, record location, and question requiring qualified review. Keep original records separate from summaries. Version the table so corrections do not erase the earlier source trail.

The related post-injury change guide explains how to document cognitive and behavioral observations after a crash. This page owns the separate task of establishing the comparison baseline.

Rosensteel Fleishman Car Accident & Injury Lawyers provides information about North Carolina personal-injury evidence questions. Medical diagnosis, causation, and legal significance require the complete records, qualified review, and the facts of the individual matter.

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