ConcussionClaim Desk
Documentation · file CON-05

Documenting symptoms

The strongest symptom record is specific, dated, and connected to function. It can include a symptom log, provider notes, work or school changes, and the instructions given during recovery.

Reviewed October 15, 20265 minute read
01

The symptom file

  1. Date and time: record the event and each meaningful change.
  2. Symptom language: use the person's own words, plus a simple intensity or frequency description.
  3. Function: record what became harder — reading, screens, driving, shifts, classes, exercise, or sleep.
  4. Care: preserve visit summaries, restrictions, referrals, and follow-up instructions.
Symptom file schematic: four record lanes of date and time, symptom language, function, and care
Fig. 1 — The four record lanes of the symptom file: date and time, symptom language, function, and care.
02

Keep the sequence intact

A file is easier to understand when it distinguishes contemporaneous notes from later recollection. Do not backfill a precise time that is not known; mark uncertainty clearly.