How to describe a baseline after brain injury

What is usual for this person

An everyday baseline describes the person's usual activities, abilities, preferences and support. Rehabilitation guidance calls for attention to what matters to the individual and how functioning varies across settings and days (National Institute for Health and Care Excellence [NICE], 2025).

Begin with the person's own account: what they enjoy, what feels manageable and how they want help. Ask one question at a time and leave space for answers. Following TBI, some people need more processing time or fewer distractions (Neumann & Lequerica, 2020).

Describe activities and the support around them

Choose one familiar activity. Record what usually happens, the setting, the support used and the person's preference. For example: “Jordan usually follows a short conversation with one person in a quiet room. Prefers time to answer and a written reminder of the plan afterward.” This is an illustrative description.

Communication rehabilitation guidance for moderate-to-severe TBI emphasizes personally relevant contexts and communication-partner support (Togher et al., 2023). Describe the actual interaction, including what helps someone take part.

Record the aids already used, such as reminders or written steps. INCOG's memory guidance emphasizes matching strategies to individual functional needs (Velikonja et al., 2023). Note which established aids the person uses and how they help.

Include variation and what helps

Ask what a good day means to the person and what becomes harder on a difficult day. VA caregiver guidance recognizes day-to-day variation after TBI (U.S. Department of Veterans Affairs [VA], 2025).

Include relevant context without assuming a cause. Fatigue can affect attention and communication after TBI (Bell, 2024). Sleep difficulties can also affect daytime functioning (Greenwald & Bell, n.d.). Record what was observed and what the person reported.

Date the description, identify contributors and keep earlier confirmed versions available. When accounts differ, retain their circumstances. This keeps the record's history understandable.

A starting prompt

“What would someone need to know to support you well tomorrow?” Add one concrete example, the help offered and the person's preference. Build the account over several conversations if that works better.