Documenting a specific change from baseline

Why documenting a specific change matters

A change can be a brief episode, an ongoing difference first noticed today or a repeat of an earlier event. The purpose of the record is to make that particular instance understandable: what was different, compared with what is usual for this person, and what happened around it.

A dated, specific account gives the next caregiver or provider more to work with than a general impression. VA's TBI guidance encourages caregivers to share detailed observations of progress and challenges at visits (U.S. Department of Veterans Affairs [VA], 2025). Keeping the person's own words alongside observations also preserves their perspective.

For behavior changes after moderate-to-severe TBI, MSKTC describes recording what happened before, during and after an event to help identify patterns and possible triggers (Hollis et al., 2021). Repeated records can support a discussion about what seems to recur, what support helped and what needs assessment. They do not, by themselves, establish a cause.

Discuss urgent-care plans with the survivor’s medical providers. This guide provides general information and documentation suggestions, not medical advice. Consult the survivor’s medical providers for clear, individualized directions on when to seek professional care or activate emergency services. NHS guidance identifies sudden new confusion as a reason for immediate medical attention (National Health Service [NHS], 2024). Recording a change or using an app should not delay urgent help.

Describe this episode and the baseline comparison

Start with one instance: what the person experienced, what someone directly observed and how it differed from that person's usual baseline. Include the activity, setting and who contributed. Use concrete descriptions rather than labels such as “not themselves.” The comparison is with this person's usual range, including familiar easier and harder days.

An illustrative note might say: “Tuesday, about 8:15 a.m. At breakfast, Jordan asked the same question four times in ten minutes. Usually follows the written breakfast plan with one reminder. Jordan said, ‘It is hard to keep track today.’ The television was on and two people were talking.”

Capture timing and the relevant baseline

Record when the difference was first noticed, how long it lasted, whether it continued or came and went, and whether a similar episode has happened before. Keep the event time separate from the time the record was written. Use “first noticed” if the actual onset is unknown, and label estimated times.

Identify the relevant baseline description and when it was confirmed, if known. NICE recommends reviewing changes in symptoms and functioning when considering rehabilitation needs (National Institute for Health and Care Excellence [NICE], 2025). If the usual pattern is not known, record that gap. A single episode should not silently redefine the baseline.

Record known causes and possible health contributors

Some changes have a medical explanation that needs assessment. Delirium, an acute change involving confusion and attention, can have causes including infection, dehydration or electrolyte imbalance, medicine effects or withdrawal, severe pain and sleep deprivation (National Library of Medicine [NLM], 2023). These are recognized causes of delirium, not an explanation for every change after brain injury.

After TBI, fatigue can affect attention, communication, mood and participation and can have several contributors (Bell, 2024). Sleep concerns may also require review of routines, symptoms and medicines with a clinician (Greenwald & Bell, n.d.). Record relevant health information that is actually known, such as reported pain, a measured temperature, an existing diagnosis, a recent medicine change or a missed dose.

Separate an identified cause from a possible contributor. If a clinician has attributed the episode to a cause, record who said so, when and the advice given. Otherwise, record the observation and the question it raises: “New medicine started yesterday; could it be relevant?” AHRQ recommends explaining symptoms and medicine concerns, asking questions and following up when symptoms worsen or instructions are unclear (Agency for Healthcare Research and Quality [AHRQ], 2012).

Check environmental and lifestyle variables

Surroundings and demands. Note noise, lighting, distractions, the number of people present, an unfamiliar setting and what the activity required. After TBI, distractions and processing demands can affect communication and attention (Neumann & Lequerica, 2020). For moderate-to-severe TBI, MSKTC also identifies pain, fatigue, noise and light sensitivity as possible behavioral triggers (Hollis et al., 2021).

Sleep, routine and activity. Record what is known about the previous night's sleep, rest breaks, physical or mental effort, appointments, travel, social activity and changes to the usual schedule. Fatigue and poor sleep can affect functioning after TBI (Bell, 2024; Greenwald & Bell, n.d.). Note recent meals and fluid intake when relevant; avoid guessing amounts or assuming that a missed meal explains the event.

Stress and social context. Include the person's account of worry, frustration, an upsetting interaction or difficulty understanding what was being asked. MSKTC describes how stress, thinking difficulties and changes in routine can contribute to behavioral difficulties after moderate-to-severe TBI (Hollis et al., 2021). Keep the person's words separate from a caregiver's interpretation.

Substances and other relevant exposures. If known and relevant, note alcohol, recreational substances, caffeine or a recent change in their use. Alcohol or drug intoxication or withdrawal can contribute to delirium, while caffeine can interfere with sleep in some circumstances (NLM, 2023; Bell, 2024). Record facts without assigning blame.

Weather and conditions at the time. If the person or caregiver considers weather relevant, record the event's time and location, the conditions reported or measured, and the source. Temperature or barometric-pressure information can remain optional context. A weather observation is not an established explanation for the episode.

Record the response and what happened next

Document support offered, the person's choices, who was contacted, advice received and the observed outcome. VA encourages TBI caregivers to bring detailed information about progress and challenges to provider visits (VA, 2025). Include whether the person returned to their usual baseline, remained different or had another episode.

For example: “We turned the television off and offered a quiet place. At about 8:35 a.m., Jordan followed the written plan with one reminder.” This records the sequence and response without claiming that noise caused the difficulty. Keep any clinician's instructions and agreed follow-up attached to their source and date; ask for clarification when needed (AHRQ, 2012).

Review the account before sharing it. Preserve unknowns, identify different observers and date later corrections. If another episode occurs, give it its own time and details so caregivers and providers can compare the events without losing the original account.