The Ophthalmology Narrative should include the following information:

• Rendering Provider's Name

History

• How did the injury occur?
• If there are any pre-existing ocular conditions, describe specifically.
• Describe nature and extent of injury, including permanent ocular defects, and/or permanent facial, head or neck disfigurement, if any, due to present injury.
• If the patient was hospitalized, give name/location of hospital and dates of hospitalization.
• Has the patient missed work because of the injury/illness? If yes, provide the date the patient first missed work?
• Is the patient working? If yes, provide the date(s) the patient:
  • Resumed limited work of any kind
  • Resumed full work

Temporary Impairment

• What is the percentage (0-100%) of temporary impairment?
• Describe findings and explain how impairment percentage was determined.

Causal Relationship:

• Was the occurrence described above (or in your previous report) the competent producing cause of the injury or disability (if any) sustained?

Physical Examination

• Attach visual field test, diagram site of injury, if applicable.
• Present condition:
  • Document corrected and uncorrected vision in each eye and all other permanent defects (all permanent defects must be known in order to determine compensation due).
• Results of interval diagnostic test, imaging studies and/or procedures performed
• Diagnostic procedure(s)/test(s) performed during the visit
• Treatment rendered at time of exam, if any

Diagnosis/Assessment

• Clear identification of diagnosis(es), including differential diagnosis (i.e., not a listing of ICD or CPT billing codes)

Treatment Plan/Recommendations:

• Proposed treatment and treatment goals (include type of treatment, frequency, anticipated duration of treatment and re-evaluation timeframe)
• Medication (prescription and over-the-counter drugs) prescribed for the injury/illness:
  • Name, dose, frequency
  • Identify discontinued medication(s) and/or changed dosage(s), including
  • reason(s) for any changes
  • Any work restrictions that may result from these medications
• Diagnostic test(s) ordered and indication(s)
• Referrals/consultations requested and indication(s)
• Follow-up appointment(s)