Elements of a Quality Narrative Report

1. Identify patient and referral sources. For example:
- Employer referred for first-time evaluation
- Patient referred self without contacting employer
- Referred by an authorized treating physician
2. Specify any additional sources of information reviewed. For example:
- Employer job description
- X-ray or lab tests
- Other medical records
3. Record patient’s history.
- Chief complaint
- Details of accident or exposure
- Occupation and job duties
- Current functional status (work related and activities of daily living)
- Pre-existing injuries, disease and functional status
4. Record physical exam. Pertinent negatives are important so be sure to examine related body regions based on mechanism of injury.
5. Describe behavioral exam when appropriate. Always assess for signs of depression in patients with chronic pain or delayed recovery.
6. Note any diagnostic tests. Note tests ordered and their results, if known.
7. List diagnoses. Be specific and use ICD-9 classification. Cumulative trauma or repetitive motion is not a diagnosis.
8. Discuss work relatedness for each diagnosis. State your opinion as to the medical probability (greater than 50%) that the diagnosis was caused by a work accident or job duties.
9. Describe treatment plan. Include expected functional goals, specific length of treatment and frequency. If treatment is outside the Colorado Medical Treatment Guidelines, justify the necessity for treatment with specific functional goals.
10. Provide detailed work and activity restrictions. Factors to consider:
- Posture: sitting, standing, kneeling, etc.
- Lifting: specify waist level, overhead, repetitive
- Repetitive movements: keyboarding, writing, pinching, tool use
- Hot or cold environments
- Special tasks: driving, climbing ladders, assembly line work
11. Describe patient education provided. Examples:
- Self management – e.g. application of heat or cold
- Exercises
- Detailed explanation of activity limitation and progression
- Natural course of condition and expected outcome
12. Record expected date of next visit and any specific referrals made.