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