Workers’ Compensation/Personal Injury Initial Injury Evaluation Note

Header

Date/Time: [Encounter date and time]

Location/Site: [Clinic or facility name]

Clinician: [Clinician name and credentials]

Case Type: [Workers' compensation / Personal injury (third-party) / Other – specify]

Date of Injury (DOI): [Date and time if known] (Do not infer. If unknown, state "Unknown" and note who will supply.)

Employer: [Employer name and worksite] (Use "Unknown" if not provided.)

Insurer/TPA: [Insurer or TPA name, adjuster name, claim number] (Use "Unknown" if not yet available.)

Attorney: [Patient attorney name and contact / None]

Case Manager: [Name and contact / None]

Chief Complaint

[Body region, symptom, mechanism, and DOI in one sentence] (Format: "[Body region] [symptom] after [mechanism] on [DOI].")

History of Present Injury

[Mechanism of injury] (Describe what happened, how it happened, forces or objects involved, body position, single event vs repetitive exposure, PPE used, environmental factors. Use selective direct quotes for key or disputed details. Do not infer specifics not stated.)

[Timeline] (DOI and approximate time, symptom onset immediate vs delayed, progression since injury, care received to date including first aid, ED, imaging, procedures, medications.)

[Body regions affected] (Primary and secondary areas with laterality. Note dominant hand if upper extremity involved.)

[Symptom characterization] (Pain quality and severity, swelling, numbness or tingling, weakness, instability, mechanical symptoms, aggravating and relieving factors.)

[Functional impact] (Effect on ADLs, sleep, and specific job task performance.)

[Work and scene details] (Job task at time of injury, shift timing, whether injury was reported, witnesses, incident report status. Include only for workers' compensation cases.)

[Red flags] (Document presence or absence of neurovascular symptoms, head injury signs, bowel or bladder changes for spine injuries, infection signs.)

Motor vehicle collision details: [Seatbelt use, airbag deployment, impact direction and estimated speed, head strike, loss of consciousness, extrication, EMS transport] (Include only if applicable.)

Fall details: [Height, landing surface, body parts impacted, head impact, ability to ambulate afterward] (Include only if applicable.)

(If information is missing, state explicitly: "Patient unable to recall..." or "Not provided at time of visit.")

Source of History

[Information source] (Patient, family member, EMS, employer representative.) [Records reviewed] (Prior notes, imaging reports, incident report, job description.) [Reliability concerns] (Language barrier, cognitive limitations, altered mental status if applicable.)

Past Medical and Injury History

[Prior injuries to same body region] (State explicitly if denied.)

[Prior surgeries to affected region] (State explicitly if denied.)

[Chronic pain conditions] (Include only if relevant to current injury.)

[Comorbidities affecting healing] (Diabetes, anticoagulation, osteoporosis, smoking status.)

Medications and Allergies

Current medications: [Medication list with doses] (Flag anticoagulants, opioids, sedatives.)

Allergies: [Allergen and reaction type]

Occupational Baseline and Job Demands

Job title: [Title and employer or department]

Work schedule: [Shifts per week, hours per shift, overtime, nights]

Essential physical demands: [Lifting weights and frequency, carrying, pushing and pulling, overhead work, climbing, ladder use, work at heights, driving, keyboarding, tool use, vibration or temperature exposure]

Baseline capacity: [Physical capacity prior to injury as reported or documented]

(If formal job description was reviewed, note date and source. If job demands are unknown, state restrictions are function-based pending job description.)

Review of Systems

[Focused ROS pertinent to injured regions] (Include relevant neurologic, constitutional, and head injury symptoms. Avoid exhaustive lists.)

Physical Examination

Vital signs: [Vital signs] (Include only if obtained.)

General: [Appearance, distress level, gait, assistive device use]

[Body region and laterality]

(Repeat this section for each injured region. Use left and right comparison where relevant. If exam limited by pain or guarding, document reason.)

• Inspection: [Swelling, ecchymosis, deformity, atrophy, wounds]
• Palpation: [Location-specific tenderness]
• Range of motion: [Active and passive ROM in degrees, end-range pain]
• Strength: [Muscle groups tested with grade 0-5]
• Neurovascular: [Sensation, reflexes, motor function, pulses]
• Special tests: [Test name and result for each performed]

Diagnostic Studies

Studies obtained today: [Imaging and labs with key findings]

Prior studies reviewed: [Outside reports or images with pertinent findings] (Specify report vs actual images.)

Studies ordered: [Tests pending with rationale]

Assessment

Diagnoses

[Diagnosis with laterality and region] (Link to supporting history, exam, and diagnostic findings. List in order of severity. Include differential diagnoses if uncertainty exists.)

Causation Opinion

Question: [Work-relatedness (arising out of and in the course of employment) / Relatedness to described incident]

Opinion: [Consistent with and more likely than not related to the described incident / Partially related with contributing pre-existing factors / Not consistent with described incident / Insufficient information to determine]

Basis: [Mechanism plausibility, temporal relationship, objective findings consistency, consideration of alternate explanations or prior history]

Limitations: [Information gaps affecting certainty and what additional information would clarify] (Do not default to relatedness without documented rationale.)

Work Status and Restrictions

Work Status: [Full duty / Modified duty / Off work]

Effective Date: [Date]

Restrictions: (Provide specific measurable limits. Omit categories not relevant.)

• Lifting and carrying: [Maximum weight, frequency]
• Push and pull: [Maximum force or description]
• Postural: [Bending, kneeling, crouching, climbing, ladder use, work at heights with frequency or prohibition]
• Upper extremity: [Overhead reach, repetitive motion, grip, tool use with side and frequency]
• Position tolerance: [Sitting, standing, walking duration and need to alternate]
• Environmental: [Vibration, temperature, confined spaces] (If relevant.)
• Safety-sensitive: [Driving, machinery, heights, commercial vehicle restrictions] (If applicable.)

Duration: [Restrictions through date / Reassess in timeframe]

Job Compatibility: [Compatible with available work / Not compatible / Function-based pending job description review]

Plan

(Organize by problem or injured region.)

[Region or Problem]

• Treatment today: [Procedures performed, medications administered, patient response]
• Medications prescribed: [Medication, dose, duration, counseling provided]
• Therapy: [PT or OT referral, home exercise program]
• DME: [Brace, splint, crutches with instructions]
• Imaging ordered: [Study and rationale]
• Referrals: [Specialty and urgency]
• Expected trajectory: [Milestones for work status progression]
• Contingencies: [Criteria for earlier return or escalation]

Patient Education and Return Precautions

[Diagnosis explained, activity guidance, warning signs for urgent reassessment, follow-up timing]

Communication and Coordination

Forms completed: [Work status report, first report of injury, other forms] (Note copies provided to patient.)

Communications sent: [Recipient, date, method] (Only as authorized.)

Outstanding requests: [Job description, incident report, prior records with source and date requested]

Attestation

Clinician Signature: [Signature]

Credentials: [Credentials]

Date/Time Signed: [Date and time]