Friday, July 29, 2011

More on Medical Narratives

The requirements of an OWCP medical report are so complicated, that physician's and Claimant's are often frustrated because they're constantly being told the report isn't good enough, requiring more and more from the Claimant's physician.

This sort of report isn't required every time you see your doctor, but it is required anytime a Claimant files for benefits or when OWCP has proposed termination of benefits for medical reasons, etc... A complete medical narrative should also be sent to OWCP at least once per year. Personally, I think every 4-6 months is better since you can never have too much good medical evidence in your file.

Once the initial report is written, any future medical treatment that occurs can be added. That way the physician just has to add any new information, include current examination results and include the examination date. S/he doesn't have to re-write the entire report.

Physician Assistants, physical therapists, registered nurses, etc…are not considered physicians under FECA and their reports will be of no value as a medical narrative.

Chiropractor reports will only be considered if Subluxation is diagnosed and confirmed by diagnostic testing.

The medical narrative must be on the physician’s letterhead and must be signed by the physician and must include the date of the examination.

Medical reports that contain phrases such as; might be, could be, probably will be given no value by OWCP. For example, the physician can't say the patient probably has a broken leg. The patient might have a bulging disc. The physician must say the patient has a broken leg. The patient shows symptoms of a bulging disc.

The OWCP recognizes the Merck Manuals. The Merck Manuals can be cited and/or quoted in the medical report. If the physician uses the Merck Manuals to enforce his/her medical opinion, it should be stated in the medical report the information came from the Merck Manuals. The link for the Merck Manuals is on the "Links" page.

The physician should be as specific as possible in his/her report.

A medical narrative must contain the following information:

The claim number and date of injury. The patient’s name, age and/or date of birth and hand dominance.

The Agency the patient is employed by, the job title of the patient and how long the patient has been working for the Federal Government.

If previous Federal jobs have been held, each additional Federal job should be listed (this includes military service).

The physical requirements of the patient’s job must be included in the medical narrative. Other factors of physical requirements should also include:
  • Some Federal jobs, such as military personnel, law enforcement, postal workers, etc…are more physical than the average job. If this is the case, it should be stated in the report
  • If the job is repetitious and/or has heavy lifting requirements, it should be stated in the report
  • If physical training is required, this should be stated along with an explanation of the training required and how often the training is required (such as military or law enforcement)
  • If the patient is required to work outside in all types of weather and/or on uneven terrain, this should be stated. Extremes in weather should be noted, such as it gets very hot and/or snow/ice.
  • Overtime requirements or overtime worked (if any) should be stated
  • If any previous Federal position was held and the physical requirements were above average (such as military service), this should be included in the report if these requirements contributed to the current condition(s)
The patient may supply the physician with the official job duties and physical requirements for reference. If the physician attaches a copy of the job duties, it must be stated in the report that the physician reviewed the job duties and a copy of the job duties reviewed is attached to the report. Otherwise, the physician must include a description of the job duties in the report.

Mechanism of injury:
It is not enough for the physician to state, for example, the patient fell off a ladder and broke their leg. For OWCP, the physician must be as specific as possible. For example, the physician must specifically state that the patient was in performance of their assigned duties, during an 8 hour day while having no medical problems (or list what medical problems they were having)when they fell off an 8’ ladder landing on the concrete floor. The force of falling 8' combined with landing on the concrete floor caused the patient’s leg to break. Any known reasons why the patient fell off the 8’ ladder should also be stated.

The physician must state what work-related activities caused or contributed to the medical condition(s). In our example above, hitting the concrete floor after an 8' fall caused the broken leg.

In the case of a consequential injury, the physician must indicate how the consequential injury is related to the original injury. For example, if the patient has an accepted knee condition and the instability of the accepted knee causes the patient to fall and injure themselves, the physician must relate the current fall to the instability of the accepted injuries. In other words, the patient would not have fallen if not for the instability of the knee. The instability of the knee comes from the accepted conditions. If the patient had never been injured originally, the current fall would not have happened. It is the original accepted injuries that caused the instability.

In the case of a fall, the physician should state any effects and/or residuals of the fall and what, if any, medical treatment was or is required because of the fall.

The physician needs to explain if any of the original accepted conditions progressed into new conditions, such as an accepted spinal disorder that causes Myelopathy or Osteophytes, medications that cause serious side effects, surgical complications from an approved surgery causing new medical conditions, an accepted psychological or physical condition that causes a sleep disorder, etc…

In the case of injuries that occur over time (Occupational injuries), the cumulative trauma should be described in detail. If the patient has repetitious or extremely physical job requirements over a long period of employment, it should be explained how the years of repetition or physical requirements caused or contributed to the patient’s current medical condition(s).

In the case of pre-existing conditions, the physician must state in detail what the pre-existing condition is/was, what symptoms it caused and explain what work-related events exacerbated, precipitated or accelerated the pre-existing condition.

The physician must relate how the injuries occurred in the course of the patient’s employment.

Medical rationale:
OWCP requires that the physician give a medical opinion and explain in detail how s/he arrived at their medical opinion and diagnosis. The physician also needs to explain why they believe or know the diagnosis is accurate.

What OWCP needs to know is exactly how the physician arrived at his/her medical opinion. How the physician knows his/her diagnosis is accurate. This is usually through examination, medical records, medical knowledge, experience and/or diagnostic test results.
The medical report also requires:

  • Physical examination results
  • Diagnostic test results
  • Treatment received, including the name and address the treatment was received and whether or not the treatment was beneficial
  • A complete diagnosis of the medical conditions. The diagnosis must include ICD-9 codes. In the case of psychological conditions, DSM codes should be used
  • Medications with dosage and side effects (if any)
  • Recommended treatment
  • Recommended diagnostic testing (if any)
  • Recommended surgical procedures (if any) with an explanation as to why the procedure is recommended and how the procedure might cure or give the patient relief from their medical condition(s)
  • Specialist referrals (if any)
The information should be listed in chronological order.

It is helpful and saves time if you list out the information about treatment, medications, physical therapy, etc...to save the physician time. The physician can check your medical records for accuracy and then transfer the information to his/her report. This is especially helpful if there has been a lot of treatment.

Here's another Jesse Slade tip...If you were required to take a pre-employment physical for your Federal employment, you should request a copy from your Agency, it should be in included in your personnel file.

If you can get a copy of your pre-employment physical, you can provide a copy to your doctor for incorporation into your narrative report. This pre-employment exam reports your physical condition prior to your Federal service and employment injuries. This can be especially useful for long term employees with extremely physical job requirements. It's a great tool for Occupational Disease (CA-2) claims.

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