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..