What information is required in a medical report?
Answer
Uh, there’s two ways of looking at this—uh, obviously doctors in, uh, in the medical field have their own requirements in terms of medical documentation—we won’t get into that—but from a workers comp perspective, your ability to receive weekly workers compensation checks depends on, uh, medical evidence, medical proof that you remain incapacitated, whether partially or totally, from the job you were doing when you were hurt. So the documentation that should be in a medical report should start always with the doctor, uh, describing or taking what we call a history, which is you reporting to the doctor how you’re feeling, what your complaints are, how it happened. Uh, in terms of the original medical that you go for—the first time you go to the doctor after you’re hurt—it’s very important to completely, um, and accurately give the doctor a history that the doctor will then document in the report of the fact that it happened at work, how it happened, what your symptoms are, and what body part or parts are injured or affected by the injury. The next thing, the doctor will perform a physical exam or perhaps take some imaging and review those and discuss them and come up with a treatment plan that, that is reasonable and necessary to, to treat you for your injuries. Lastly, the medical documentation should contain some statement about your ability to work and, um, say, for example, that the patient is partially disabled or totally disabled, uh, or, uh, can work but has restrictions. If you are, uh, restricted in any way from doing your full duties, you can be considered partially disabled and entitled to workers comp benefits, and that’s all important medical documentation that we, workers compensation lawyers, rely upon and need to do our job on your behalf.