<Date>
<Insurance Company Name>
<Address>
<City, State Zip>
Re: <Patient’s
Name>
Claim Number: < >
Chief Complaint:
1.<list area of complaint>
2.<list area of
complaint>
3.<list area of
complaint>
4.<list area of
complaint>
Subjective: Provide the history including:
- date of initial onset
- how the condition
began
- body part involved and
the associated frequency (absent,
occasional, intermittent, or constant), intensity (none,
slight, moderate or severe), and duration
- what increases and
decreases the symptoms
- describe the pain
quality (sharp, dull, throbbing, achy, numbness, burning, tingling)
- radiation from where to
where and how long it lasts
- change in the symptoms
based on the patient’s location during the day
- change in the symptoms
base on the time of day
The patient was first seen in this office on <list first date seen in your office for this onset> for
examination, treatment for the above chief complaints. At that time
[For each chief complaint listed above
use this paragraph to describe the subjective. Keep the same order as
the chief complaints listed above.]
The <body part involved> pain began on <date > when the patient <describe how it happened>.
The pain was described as <occasionally,
intermittently or constantly> <sharp, dull, throbbing, achy,
numbness, burning tingling> that increased with < list >
and decreased with <list >.
A) There was no radiation in this area. OR
B) The pain traveled from <list > to <list > and lasted for < seconds, minutes, hours, days > when it occurs.
A) There was no change in the pain with
change in the patient’s location during the day. OR
B) The pain increased when the patient <describe the location> and increased when the patient was <describe the location>.
A) There was no change with the time of
day. OR
B) The pain was <absent, present,
increased, decreased> in the <morning, late morning, afternoon,
evening, night time>.
Past history showed <list any motor vehicle
accidents, surgeries, hospitalizations which have a bearing on the
complaints> and <has / has no> residuals form these.
Treatment has consisted of <list the
therapies> which have been administered at <home, office,
health providers office>.
The patient was last seen in this office on <list the last treatment date>. At that time the patient had <list the subjective complaints frequency, intensity and duration>.
Laboratory
Tests:
No laboratory tests have been performed
for this injury. OR
A <list the laboratory test> was/were
performed on <list the date of the test> which showed no
abnormalities. OR
A <list the laboratory test> was/were
performed on <list the date of the test> which showed the
following to be increased: <list the ones which are increased>;
and the following to be decreased: <list the ones which are
decreased>.
Progress and
Discussion:
<Summarize the highlights of the patient’s
subjective and objectives for each of the chief complaints when they
were originally seen in your office.>
After a clinical course of <list the number of
treatments since the last evaluation> treatments consisting of
<list the therapies>, the patient was re-evaluated on <give
date of re-eval>.
[Select
the ones below that apply to your patient’s treatment response.]
A) The evaluation showed <no, little,
some, good, excellent> improvement in <list the subjective and
objective improvements and body area>.
B) There was < no change/worsening>
in <list the subjective and objective for the body areas>.
C) The patient is still in need of
treatment consisting of <list the therapies>. Over the next
<list the number of days/weeks> I anticipate the patient will need
<number of visits> treatments.
D) The patient’s progress has been
<good/steady/slow/poor>.
E) The patient’s condition is improving
as well as can be expected considering the nature of the injury.
F) The patient is impaired due to
<list the cause>.
G) The patient plans to return to work on
<date>.
H) The patient <is / is not>
disabled from work.
I) The patient is released as of
<date> to return to work with <full/restricted> duties.
Work restrictions include <list the activity and how long they
can/cannot do the activity>.
J) The patient has been discharged from
care at a maximum medical improvement on <date> with the
following home care instructions <list the home care>.
K) The patient has been discharged from
care at a pre-injury status on <date> with the following home
care instructions <list the home care>.
L) The patient was referred to <list
name of the doctor>. The patient <is / is not> to return to
this office for additional treatment of <list the complaint>.
M) The patient is to return to this office
for additional treatment for the above chief complaints.
If you have any questions, please feel free to
contact me.
Sincerely,
<Your Name>
