Sample: Initial Report By Primary Treating Physician or Consultant

The initial report of the Primary Treating Physician or Consultant is one of the most important documents in a claim. It is typically written reasonably close to the time of injury so that facts are clear in the mind of the Injured Worker. It is also read closely by the Claims Examiner. With a comprehensive, chronologic rendering of how the injury occurred, what the worker was doing at the time of the injury, when and to whom the injury was reported and the chronologic history of treatment from the date of injury to the date of the exam, any inconsistencies can be resolved early in the claim. In addition, the Physician must take the time to understand exactly what the injured worker does in the course of his/her normal work duties to be able to do proper disability management. This is the time to concentrate on the details of the past non occupational medical history including medication usage and drug allergies to avoid iatrogenic complications by drug interactions with other medication or with medical conditions.

Initial Report By Primary Treating Physician or Consultant

Date

Insurance Company:
Address:
Attn: Adjuster (if known)

Re: Name of Injured Worker
Employer:
Date of Injury (DOI):
Claim Number:
Date of Exam:


Dear:

Mr./Ms./Mrs.               is a (age) –year-old, (race/ethnic group), (male/female), who was seen for initial evaluation on              (date of exam).

He/She is accompanied by a(n)              -speaking interpreter (if used).

History of Present Injury.Illness as Presented by Patient

When and how did the injury occur? Include time and description of the activity he/she was performing at the time of the injury.
When was the injury reported, and to whom?
What symptoms did the patient describe at the onset of the illness/injury and what was the progression with time?
The chronologic sequence of treatment rendered to the patient from the date of injury until the current evaluation in your office

If there was no injury, explain how the patient relates his/her complaints to his/her job.

Present Complaints

The current symptoms describing the intensity, frequency and activities which would precipitate or worsen the symptoms.

Past HistoryRelated to this body part

Note any prior injury (workers’ compensation, personal injury or athletic injury) specifically to this body part or any past treatment to the body part not necessarily related to an injury.

Occupational History

Include job title and description of the patient’s normal work activities. Probe for the extent and frequency of activities such as lifting, climbing, bending etc so that you as the examiner have a strong sense of the patient’s normal work duties. This will be essential for disability management as you must understand what the patient would normally do at work.

How long had the employee worked for his/her current employer prior to the injury or onset of illness? Briefly describe prior work history. This may be particularly relevant and may require more detail in cases of cumulative trauma or occupational disease What is the patient’s work status at the time of the examination. If the patient is on modified or light duty, what are the restrictions?

Past Medical History

Question the patient regarding any general medical conditions or illnesses (i.e. diabetes, hypertension, heart disease, liver disease, kidney disease). This should prevent any iatrogenic complications of medication which you might recommend that may react with a medical condition

Medications

What medication is the patient taking at present, both for the injury and for medical conditions other than the injury. Again, this would prevent any drug interactions

Drug Allergies

List any drug allergy or drug reaction the patient has had in the past.

Physical Exam

For spine and extremity examination always include:

• inspection
• palpation
• active/passive range of motion
• neurologic examination
• strength (jamar, pinch, manual testing)

Diagnostic Testing

Include results of x ray, imaging studies or any other laboratory tests.

Diagnosis(es)

Provide a specific diagnosis consistent with your findings above.

Record Review

List any available medical records related to the injury/illness that you have reviewed. Include the date and physician’s name with a brief summary of their contents.

Causation

Is the condition all or partly due to occupational factors and explain why you reached this conclusion.
(If apportionment is an issue, address this only when patient is permanent and stationary.)

Treatment Plan

If further treatment is needed, outline the planned course, frequency and duration of treatment.
Give the date of the patient’s follow up appointment in the office.

Disability Status

Temporarily totally disabled, meaning the patient cannot work in any capacity. What is the expected length of the TTD?

Temporarily partially disabled, meaning the patient cannot return to full duties, but can return to modified work with the restrictions specified in your report. Specify for example, the number of pounds the patient is restricted from lifting; and any specific activities such as standing, pushing, etc., which are precluded or limited. Specify what date the patient can return to the modified duty.

Able to return to full duties, but not yet permanent and stationary. In this situation the patient is able to perform his/her usual job duties but has not been discharged from care.

Vocational Rehabilitation

Comment only if the patient is expected to be medically eligible for vocational rehabilitation services due to permanent residual impairment related to the industrial injury/illness.

Discussion (optional)

Summarize the highlights of the exam and treatment plan.

Affidavits/Disclosures

All reports should conform to the requirements of Title 8CCR 10606, which lists the elements, which should be included in the report.

For a medical report to be admissible as evidence, California Labor Code Section 5703(a)(2) now requires physicians to include a declaration in the body of the report substantially as follows:

“I have not violated Labor Code 139.3 and the contents of this report are true and correct to the best of my knowledge. This statement is made under penalty of perjury.”

DATE OF REPORT             
Dated this               day of              ,20   
at               County, California

DOCTOR’S SIGNATURE (must be original) Credentials (specialty, board certification, fellowship, etc.)