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Workers’ Compensation Board

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CMS-1500 Medical Narrative Requirements

PT/OT Narrative Report

The PT/OT Narrative requires the following information:
Clinical documentation to support PT/OT care and services must be consistent with MTG General principles and recommendations.

  • Rendering Provider's Name
  • Referring Physician's/Provider's Name
    • What was the frequency and period of the treatment ordered?
  • Diagnosis(es) of referring physician/provide
  • Examination findings
  • Evaluation/Assessment or re-evaluation/re-Assessment of the patient's condition including progress/gains toward specific objective functional goals related to work or activities of daily living (that the patient was able to perform prior to the injury and must be able to perform to return to work.) Were identified goals met? If not, comment on re-evaluation and/or change in treatment plan.
  • Plan of Care: Treatment plan including plan for identification of ongoing specific objective functional goals and re-evaluation of treatment.