Traumatic brain injury (TBI), a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain.
TBI can result when the head suddenly and violently hits an object, or when an object pierces the skull and enters brain tissue. Symptoms of a TBI can be mild, moderate, or severe, depending on the extent of the damage to the brain. A person with a mild TBI may remain conscious or may experience a loss of consciousness for a few seconds or minutes.
Mild TBI: include headache, confusion, lightheadedness, dizziness, blurred vision or tired eyes, ringing in the ears, bad taste in the mouth, fatigue or lethargy, a change in sleep patterns, behavioral or mood changes, and trouble with memory, concentration, attention, or thinking.
Moderate or severe TBI may show these same symptoms, but may also have a headache that gets worse or does not go away, repeated vomiting or nausea, convulsions or seizures, an inability to awaken from sleep, dilation of one or both pupils of the eyes, slurred speech, weakness or numbness in the extremities, loss of coordination, and increased confusion, restlessness, or agitation.
Essential Medical Documentation of TBI Needed for Disability Benefits:
- How long has the condition affected you?
- What medication is prescribed and effects of the medication?
- Do you have difficulty with your memory?
- How does the condition impact you in your daily life? (substantial impact?)
- How does the condition impact your ability to concentrate, follow directions, stay focused and on task? (substantial interference?)
- How does the condition impact your ability to interact with others? (substantial interference?)
- Have you required any hospitalizations for your condition?
- Have you been fired or reprimanded from work for your condition?
SSA utilizes the term "Impairments" (and resulting "limitations" - why you cannot work) are the essential bits of information that must be clearly and consistently documented throughout your medical history by the treating sources (medical doctors, psychologists, psychiatrists).
SSA additionally utilizes the term "Residual Functional Capacity" (RFC); this is a key concept related to the resulting physical and/or mental impairments from conditions for which the disability claim is based upon and the impact upon ability to work.
SSA has its own forms that are used for Physical RFC here and for Mental RFC here. These forms can be filled out by the treating source who has the opportunity to examine the patient and understand the limitations which result from his/her condition and thereby document with specificity in the language of SSA disability.
SSA "Listing" or "Blue Book" description for traumatic brain injury (TBI) can be found here (See 11.18)
Your disablity lawyer must work closely with your treating physician to get the proper documentation of your specific findings and impairments into the medical records. At Law Med that's what we do.