Narrative Progress Report - Blue Poppy



What Goes in a Narrative Report?

These types of reports may be used for Worker’s Comp, PI, or any other insurance case where reports are required.

1. An initial narrative report should include the following:

Report Date

Patient Name and Age

Date of Treatment or Services

Patient Chief Complaint

Medical History

Description of Accident, Incident, or Illness including Cause

Diagnosis

Treatment plan with time-limited goals

Prognosis

A statement on why prior or alternative conservative measures may have failed or are not appropriate as sole treatment.

A summary of any consultations that have been obtained, particularly those that have addressed factors that may be barriers to recovery.

A statement that the attending practitioner has conducted appropriate screening for factors that may significantly increase the risk of adverse outcomes (e.g., a history of alcohol or other substance abuse).

Enclosures: If any. Such as lab reports or imaging studies

On-going Narrative Progress Report

Some insurance companies require a monthly progress report before payment for continuation of treatment. In the case of Worker’s Compensation, a weekly progress report may be required. Since a narrative report requires time to prepare, you may bill the insurance company for it.

An on-going narrative progress report should contain:

Report Date

Patient Name and Age

Date of Treatment or Services

Patient Chief Complaint

Medical History

Other Treatments for the Disorder

Description of Accident, Incident, or Illness including Cause

Objective Clinical Findings

Diagnosis

Treatment

Prognosis

Enclosures: If any. Such as lab reports or imaging studies

Sample Narrative Report:

April 20, 2004

Gordon P. Stone

National Insurance Company

P.O. Box 7744

Columbus, OH 67822

Dear Mr. Stone,

Susan Martin first came to this office on February 5, 1997 seeking treatment for injuries which were sustained during a motor vehicle accident which occurred on February 1, 2004. Mrs. Martin is a female who was born on 6/8/63.

DESCRIPTION OF INJURY/ONSET

On the initial visit, Susan reported the following symptoms:

- headaches which were described as severe in intensity

- upper neck pain on both sides which was described as moderate to severe in intensity

- lower neck pain on both sides which was described as moderate to severe in intensity

- shoulder pain on the right side which was described as moderate in intensity

- shoulder pain on the left side which was described as moderate in intensity

- chest pain and difficulty breathing when at its worst

Mrs. Martin relates that at the time of the accident she was the driver of a vehicle which she describes as a compact car which was stopped. Susan stated that the other vehicle involved in the primary impact of the accident is best described as a full size truck. During the accident the vehicle that Mrs. Martin was in was struck squarely from behind by the other vehicle involved in the primary impact of the accident.

At the time of the accident, Mrs. Martin states that she was not wearing her seat belt and was not wearing her shoulder harness. The airbag in Mrs. Martin's vehicle did not deploy. Susan indicates that she was not anticipating the impact and was not braced. At the point of the impact she was looking straight ahead. Mrs. Martin does not believe she lost consciousness due to the trauma of the accident.

INITIAL EXAMS/RADIOGRAPHS

After the history was taken, the following exams were performed: General Exam on 2/5/04, Cervical Exam on 2/5/04.

The following radiographs were ordered and evaluated to assist in arriving at a differential diagnosis and treatment plan: APOM, APLC, LCN, LCF, and LCE.

PHYSICAL EXAM FINDINGS

Susan's weight was reported to be about 112 pounds. Her height was reported to be about 61 inches. Susan's pulse rate was measured at 70 beats a minute. Susan's temperature was measured and found to be 97.8 degrees. Blood pressure of the right arm was taken while Susan was seated and found to be 120/70 mmHg.

INITIAL EXAM FINDINGS

Significant findings from the first examination(s) include:

- a positive Cervical Compression test with the patient's head in a neutral position

- a positive Foraminal Compression test with the head tilted to the right

- a positive Foraminal Compression test with the head tilted to the left

- positive right shoulder depression and positive left shoulder depression

INITIAL RANGE OF MOTION FINDINGS

ROM findings from the first examination(s) include:

First Cervical ROM - February 5, 2004

Flexion (Flex) 30

Extension 25

Rt Rotation 65

Lft Rotation 60

Rt Lat Flex 30

Lft Lat Flex 35

DIAGNOSIS

Based upon the history, symptoms, and objective findings, the following initial diagnosis was rendered on February 5, 2004:

PRIMARY, Acute, and Moderate Migraine 346.9

Acute Cervical Myofascitis 729.1

Acute and Moderate Cervicalgia 723.1

ASSESSMENT

The health history indicates that the condition which Mrs. Martin presented with is a new condition.

Based upon a review of the mechanism of injury and the information contained in the literature which relates to these conditions I can say with a reasonable degree of certainty that the conditions identified are the direct result of the trauma sustained in the accident. The accident occurred on February 1, 2004.

TREATMENT PLAN

In order to address the conditions identified, the following procedures were provided to Mrs. Martin under the initial treatment plan which was established on February 5, 2004:

- Acupuncture treatments

- Out of office cryotherapy

- Electrical myo-stimulation (EMS)

The following limitations were established as part of that treatment plan to avoid exacerbation of Mrs. Martin's condition:

- Work must be limited to 8 hours or less a day

- No lifting of any object over 10 pounds

- Until further notice, no sports activities, no jarring activities, activities which may result in a fall, and activities which may result in a blow to the body or head

- No repetitive motions involving the neck and arms

- Until further notice, no vacuuming, mopping, and reaching over her head

Mrs. Martin was scheduled to be seen at a rate of approximately 2 to 3 times a week. This frequency of care was designed to continue for 4 to 5 weeks. This treatment plan includes an examination at the end of the scheduled care to re-evaluate Mrs. Martin's condition and evaluate her progress.

MONITORING EXAMS

Mrs. Martin's progress was monitored by performing the following examinations: Cervical Exam on 4/5/04.

MOST RECENT EXAM FINDINGS

Significant findings from the most recent examination(s) include:

- a positive Cervical Compression test with the patient's head in a neutral position

MOST RECENT RANGE OF MOTION FINDINGS

ROM findings from the most recent examination(s) include:

Most Recent Cervical ROM - April 5, 2004

Flexion (Flex) 50

Extension 35

Rt Rotation 85

Lft Rotation 85

Rt Lat Flex 50

Lft Lat Flex 50

ACTIVITIES OF DAILY LIVING ASSESSMENT

On February 6, 2004, the patient completed a Neck Pain Disability Index Questionnaire. This subjective test measures the degree of functional impairment of individuals with neck pain. Susan scored a 46%, or moderate disability in the ability to perform the normal activities of daily living. A final Neck Pain Disability Index Questionnaire was completed by Susan on April 5, 2004 and she scored a 20%, or mild disability.

PROGRESS REPORT

The progress that Mrs. Martin made during the course of treatment was uncomplicated.

A review of the examinations shows significant increase in the cervical range of motion.

The final review of examinations shows that over the course of treatment there was a marked reduction in positive orthopedic findings, palpable edema, palpable

myospasm, and tenderness.

LIMITATIONS

In her current condition, Mrs. Martin should avoid having her head tilted backward for any length of time and sleeping on her stomach.

PROGNOSIS

Mrs. Martin can anticipate periodic flare-ups of symptoms due to normal activities associated with daily living. The periodic flare-ups will likely require some level of acupuncture intervention.

Sincerely,

David T. Point, Lic. Ac..

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