Work-Relatedness and Causation Narrative Report

Report Date: [Report date] (If unavailable, enter "Not provided".)

Evaluation Date(s): [Evaluation date(s)] (Note modality as [in-person / telehealth / records-only]. If unavailable, enter "Not provided".)

Evaluator: [Name, credentials, specialty, board certifications, contact information]

Patient: [Full name] | [Date of birth]

Claim Information: [Claim number] | [Date of injury] | [Employer name] | [Insurer/TPA] (Enter "Not provided" where missing.)

Referral Questions:

• [Referral question] (Add or remove as needed.)

Sources Reviewed

• Clinical records: [Notes, imaging reports, diagnostic studies with dates and providers]
• Occupational materials: [Job description, incident report, physical demands analysis, other relevant materials]
• Collateral sources: [Statements, prior claim files, other sources] (If applicable.)

Reliability statement: [Brief appraisal of record completeness, discrepancies, and degree of reliance on patient report]

Executive Summary

(Keep to 6–12 lines. Use clear probability language. This section must stand alone for readers who review only the summary.)

• Diagnoses and work-relatedness conclusions: [Diagnosis: more likely than not work-related / not work-related / work-related aggravation of pre-existing condition / indeterminate with reason] (Repeat for each diagnosis.)
• Key rationale: [2–4 points addressing mechanism consistency, temporal relationship, objective support, and alternative etiologies considered]
• Current work status: [Full duty / Modified duty / Off work] (If modified, list headline restrictions.)
• Recommended next steps: [Diagnostics, consults, workplace interventions, or records needed]

Background and Mechanism

Claimed event or exposure: [Date, location, and circumstances of injury or exposure onset with mechanistic details]; [Brief patient quote if mechanism-critical], translated into clinical terms: [Clinical description of forces, exposures, posture, loads, repetition, duration]. (If unavailable, state "Not provided" and list what is needed.)

Chronology: [Timeline from symptom onset through initial care, diagnostics, treatments, response, and current status]. (Distinguish dates verified in records vs. patient-reported.)

Prior related history: [Prior injuries to same body region, pre-existing conditions, prior claims, baseline function]. (Include only if relevant to causation.)

Non-work risk factors: [Age-related changes, comorbidities, recreational activities, other relevant factors]. (Include only if pertinent to differential etiology.)

Current symptoms and functional impact: [Location, quality, severity, functional limitations compared to pre-injury baseline]. (Label clearly as patient-reported.)

Verification from records: [Aspects of history corroborated or contradicted by contemporaneous records or objective data]

Objective Findings

(Include only clinician-observed or measured findings with key positives and relevant negatives.)

• Physical examination: [Pertinent findings by region; ROM, strength, neurologic findings, special tests as relevant]
• Imaging and diagnostics: [Study, date, source, key findings with acute vs. chronic features noted]
• Other objective data: [Functional testing, exposure measurements, ergonomic analyses as applicable]

Causation Analysis

Causation standard applied: [Within a reasonable degree of medical probability / More likely than not / Jurisdictional standard if specified]

Key term definitions: [Define terms central to the reasoning, e.g., aggravation, radiculopathy, degenerative change]. (Include only when essential to understanding the analysis.)

[Diagnosis 1]

• Diagnostic support: [Is the diagnosis supported by objective findings? Address competing diagnoses.]
• General causation: [Is the claimed mechanism capable of causing this condition? Reference biomechanics or toxicology where applicable.]
• Specific causation: [Exposure magnitude, temporal relationship, dose-response, anatomic concordance, consistency with natural history in this case.]
• Alternative etiologies: [Non-occupational risk factors, pre-existing pathology, idiopathic causes considered and why less likely or contributory.]
• Nature of work effect: [New condition / Temporary symptom aggravation / Permanent aggravation of pre-existing pathology / No material contribution] with justification.
• Opinion statement: [Explicit conclusion using probability language]
• Information gaps: [Specific data needed to reach conclusion] (Only if indeterminate.)
• Apportionment: [What is apportioned (pathology vs. symptoms vs. impairment); weighting basis; whether percentages are supportable or only qualitative weighting] (Only if requested or required.)

(Repeat the above structure for each additional diagnosis addressed.)

Work Status and Recommendations

• Current work status: [Full duty / Modified duty / Off work] (Base on objective findings and safety, not pain report alone.)
• Restrictions: [Specific quantified limits with anticipated duration and criteria for progression] (If applicable.)
• Diagnostic/treatment next steps: [Recommended tests or consults with rationale for how each clarifies diagnosis or causation]
• Workplace interventions: [Ergonomic review, exposure controls, job site evaluation, transitional duty options] (If applicable.)
• Information requested: [Missing records, exposure measurements, or other data needed] with explanation of how each affects the analysis.

Limitations: [Missing records, assumptions made, reliance on patient report]. (If missing information could materially change opinions, label specific opinions as conditional.)

Attestation: The above opinions are rendered objectively and within [the stated probability standard], based on the information available at the time of this evaluation.

Signature: [Evaluator name, credentials] | [Date]