After a concussion, work, reading, screens, sleep, driving, walking, balance, noise, light, and multitasking may not change in the same way or on the same schedule. A statement that someone felt better or worse does not show which activity was attempted, what happened during it, or what medical instruction applied at the time.

A concussion activity record should identify the dated task, baseline, duration, environment, reported symptom, observed change, pause or modification, provider instruction, source, and unresolved medical question without directing return to activity.

Follow medical guidance and record it accurately

The CDC’s mild TBI and concussion guidance advises people to obtain care, follow health-care-provider instructions, and discuss symptoms that worsen or do not improve. It also addresses a gradual return to regular activities under appropriate guidance. A legal-information article cannot determine whether a person has a concussion or when a particular activity is medically appropriate.

  • Provider, visit date, assessment, written instruction, restriction, medication, referral, follow-up, warning sign, and source document
  • Instruction effective date, activity covered, duration if stated, change, clarification request, and person who confirmed it
  • Urgent or worsening concern routed to the appropriate health-care channel rather than held for a claim discussion
  • No generic rest, work, driving, exercise, screen, or return-to-activity rule substituted for the person’s medical guidance

Track work and cognitive tasks

  • Job task, schedule, commute, meeting, reading, writing, calculation, memory, decision, telephone, video call, noise, lighting, and interruption level
  • Start time, duration, break, modification, assistance, error, unfinished task, reported symptom, and recovery period
  • Employer instruction, provider restriction, accommodation request, schedule change, leave, attempted return, and actual result
  • Pre-injury work and cognitive baseline supported by records or a person with first-hand knowledge

Describe screen and visual-demand changes

  • Device, distance, font or scale, brightness, contrast, motion, audio use, room lighting, glare, duration, and task
  • Headache, eye strain, dizziness, nausea, focus difficulty, fatigue, or other reported experience stated in the person’s own words
  • Pause, shorter session, printed material, audio alternative, changed setting, assistance, or task substitution
  • Provider instruction or device recommendation recorded separately from a self-selected modification

Keep sleep information in a dated log

  • Bedtime, wake time, awakenings, estimated duration, nap, schedule change, environment, and source
  • Medication or instruction recorded from its source without claiming it caused a particular sleep result
  • Reported sleep quality separated from an observer’s account, device estimate, clinical assessment, or diagnosis
  • Work schedule, travel, caregiving, pain, noise, light, illness, or another event retained as context rather than ignored

Record balance and movement observations neutrally

  • Walking surface, stairs, turn, transfer, vehicle entry, crowd, low light, carrying task, distance, duration, footwear, assistance, and device
  • What the person reported and what another person directly observed kept in separate fields
  • Stumble, pause, hand support, missed step, changed route, stopped activity, or other observable event described without diagnosing its cause
  • New fall, impact, illness, medication change, treatment, or intervening event added to the chronology

Collect the underlying medical and billing records

HHS explains that, with limited exceptions, the HIPAA Privacy Rule permits access to medical and billing records in a covered provider’s or health plan’s designated record set. Its medical-record guidance also addresses copies and amendment requests. Preserve the original record, request, response, addendum, and any statement of disagreement rather than rewriting the clinical record.

  • Emergency, primary-care, consulting-provider, therapy, imaging, testing, pharmacy, work-status, and follow-up records indexed by date and provider
  • History reported separated from examination, test result, assessment, instruction, restriction, prognosis, and later change
  • Missing range, outside provider, portal message, telephone note, referral, raw test data, work note, or bill listed as an exception
  • Charge, adjustment, insurer or benefit payment, personal payment, refund, and balance reconciled by account and date

Separate observation from medical or technical opinion

North Carolina Rule of Evidence 701 addresses lay opinion grounded in a witness’s perception when it is helpful. Rule 702 addresses qualified expert testimony. A person can record a reported symptom or observed activity, but diagnosis, medical cause, prognosis, permanency, treatment need, or legal value may require a different foundation.

Use a repeatable activity log

  • Date and time, task, baseline, environment, duration, reported symptom, observed event, change made, and source
  • Provider instruction, work or school record, witness, clinical record, device record, conflict, and missing item
  • Improvement, worsening, fluctuation, new event, attempted return, easier day, and difficult day retained with context
  • Question reserved for a health-care provider or matter-specific review and the date it was asked or answered

The related guide to establishing a pre-injury cognitive and functional baseline after a head injury covers the comparison point. This page owns the repeated post-event work, screen, sleep, balance, and activity-attempt log.

Rosensteel Fleishman Car Accident & Injury Lawyers provides general information about Charlotte personal-injury claims. Concussion symptoms, restrictions, and return-to-activity decisions should be evaluated by qualified health-care professionals.

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