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Workers' Compensation Board

CMS-1500 Ophthalmology Narrative Report


Ophthalmology Narrative Report

The Ophthalmology Narrative should include the following information:

  • Rendering Provider's Name

History

  • How did the injury occur?
  • If there are any pre-existing ocular conditions, describe specifically.
  • Describe nature and extent of injury, including permanent ocular defects, and/or permanent facial, head or neck disfigurement, if any, due to present injury.
  • If the patient was hospitalized, give name/location of hospital and dates of hospitalization.
  • 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

Temporary Impairment

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

Causal Relationship:

  • Was the occurrence described above (or in your previous report) the competent producing cause of the injury or disability (if any) sustained?

Physical Examination

  • Attach visual field test, diagram site of injury, if applicable.
  • Present condition:
    • Document corrected and uncorrected vision in each eye and all other permanent defects (all permanent defects must be known in order to determine compensation due).
  • Results of interval diagnostic test, imaging studies and/or procedures performed
  • Diagnostic procedure(s)/test(s) performed during the visit
  • Treatment rendered at time of exam, if any

Diagnosis/Assessment

  • Clear identification of diagnosis(es), including differential diagnosis (i.e., not a listing of ICD or CPT billing codes)

Treatment Plan/Recommendations:

  • Proposed treatment and treatment goals (include type of treatment, frequency, anticipated duration of treatment and re-evaluation timeframe)
  • Medication (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)
  • Follow-up appointment(s)