What to document for Traumatic Brain Injury
Organize disability evidence for cognitive limits, headaches, mood, therapy records, and work pace.
| Evidence area | What makes the record more useful |
|---|---|
| Cognitive Limits | Connect cognitive limits to specific activities and work demands instead of using a conclusion without examples. |
| Headaches | Track headaches over time: frequency, duration, recovery time, and how it changes reliable activity. |
| Mood | Track mood over time: frequency, duration, recovery time, and how it changes reliable activity. |
| Therapy Records | Show the history of therapy records, response, side effects, and whether the treatment changed day-to-day function. |
| Work Pace | Connect work pace to specific activities and work demands instead of using a conclusion without examples. |
How Traumatic Brain Injury affects work function
Describe function in concrete terms that match this condition and the person's actual work history. Useful records may address reliability, pace, attendance, safety, physical tolerance, communication, concentration, or adaptation depending on the symptoms documented in the file.
- Use examples from treatment records and daily activity rather than a diagnosis label alone.
- Identify how often a limitation occurs and how long recovery takes.
- Separate limitations caused by this condition from other impairments when the records allow it.
- Explain treatment gaps, side effects, or inconsistent findings instead of ignoring them.
SSA medical sources for Traumatic Brain Injury
The Listing of Impairments is one part of disability evaluation. A claim can also turn on the combined medical record, residual functional capacity, past work, and other steps in Social Security's evaluation process.
Questions before an appeal or hearing
- Which cognitive limits records cover the period SSA is reviewing?
- Do the records explain headaches with enough detail to show frequency or severity?
- How does work pace affect the claimant's past job duties or reliable attendance?
- What recent record has not yet been added to the disability file?