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Workers' Compensation Board

CMS-1500 Medical Narrative Requirements


Initial Narrative Report

The Initial Narrative Report should include all the requirements below.

  • Rendering Provider's Name

Work Status

  • Has the patient missed work because of the injury/illness? If yes, provide the date the patient first missed work?
  • Is the patient working? If yes, provide the date(s) the patient:
    • Resumed limited work of any kind
    • Resumed full work
  • If the patient is not working, can the patient return to usual work activities as indicated?
  • Are there any work limitations? (If so, explain and quantify, including the anticipated duration of the limitations)

Temporary Impairment

  • What is the percentage (0-100%) of temporary impairment?
  • Describe findings and explain how impairment percentage was determined

Doctor's Opinion (Based on this Examination) - Causation

  • Indicate if, in your opinion, the incident that the patient described was the competent medical cause of this injury/illness.
  • Indicate if the patient's complaints are consistent with his/her history of the injury/illness.
  • Indicate if the patient's history of the injury/illness is consistent with the objective findings or if it is not applicable at this time.

History of the Injury/Illness

  • Where and how the injury/illness occurred
  • Details regarding the nature of injury/illness. Identify specific body part(s) affected
  • Symptoms and relevant review of symptoms (e.g., onset, duration, associated symptoms, alleviating and exacerbating factors)
  • Function:
    • On the date of injury/illness what was the patient’s job title and usual work activities
    • Specific functional work activities and/or Activities of Daily Living (ADL) that patient cannot perform as a result of injury/illness
  • Previous treatment for the injury/illness including hospitalization and/or surgery and reported patient response (effectiveness of treatment)
  • Relevant medical history, including:
    • Any prior treatment for a similar work-related injury/illness and/or
    • Any prior injury or treatment to the affected body part(s)
  • Medications
    • Clear documentation of current medications including dose, frequency and patient response, and
    • History of previous medications and patient response

Objective Findings/Clinical Evaluation

  • Physical examination (describe all relevant findings according to History Taking and Physical Examination sections found in each Medical Treatment Guideline and per standard clinical practice for non-MTG injuries)
  • Diagnostic procedure(s)/test(s) performed prior to the visit
  • Diagnostic procedure(s)/test(s) performed during the visit
  • Treatment rendered at time of exam, if any (e.g., casting, suture/suture removal, injections)

Diagnosis(es)/Assessment

  • Clear identification of diagnosis(es), including differential diagnosis (i.e., not a listing of ICD or CPT billing codes)
  • Identify patients with delayed recovery (pain and functional limitations that persist beyond the anticipated time of healing and recovery) early and evaluate per Non-Acute Pain Medical Treatment Guidelines (NAP MTG)

Plan of Care

  • Proposed treatment and treatment goals (include type of treatment, frequency and anticipated duration of treatment)
  • Assess for delayed recovery and treat as indicated per NAP MTG recommendations
  • Medications (prescription and over-the-counter drugs) prescribed for the injury/illness:
    • Name, dose, frequency
    • Identify discontinued medication(s) and/or changed dosage(s), including reason(s) for any changes
    • Any work restrictions that may result from these medications
  • Diagnostic test(s) ordered and indication(s)
  • Referrals/consultations requested and indication(s)
  • Assistive devices prescribed
  • Prognosis for recovery
  • Follow-up appointment(s)