For clinicians · Piper Education
TMJ trauma history, documented once and correctly.
Record one traumatic event in enough detail that the examining doctor can reconstruct it, mentally or with diagrams. The tool assembles a structured documentation summary for the record.
One form per traumatic event. Combining events on one form creates ambiguity that is exploited in deposition. Record what the patient tells you without answering for them; where a detail cannot be recalled, note that it cannot be recalled. Nothing entered here leaves this page.
Incident
Position of the head, direction of force, restraint, airbag, loss of consciousness, what struck the face or jaw.
Onset of joint symptoms
Clinical note. Joint noise beginning 4 to 12 weeks after whiplash is consistent with the retrodiscal cascade: retrodiscal swelling displaces the condyle down and forward, the posterior occlusion opens, repeated closure into maximal intercuspation compresses the swollen attachment against the posterior band, the collateral ligaments loosen, and the disc displaces. Document the timing explicitly.
Symptoms since the trauma
Symptoms before the trauma
Where any symptom predates the event, the burden falls on the examiner to differentiate when the majority of symptoms began, from the oral history and prior medical and dental records.
Litigation and other events
Documentation summary