The following table lists the current CMS elements of a patient history in comparison to the proposed elements appropriate for an Occupational Medicine workers’ compensation related function-oriented encounter. Note: Family History elements that may reveal hereditary diseases are replaced with Family History elements that relate to risk of work disability; documentation of hereditary diseases should only be done if directly relevant to the work injury or illness, due to prohibitions in the Genetic Information Nondiscrimination Act (GINA). We recognize that the proposed Family History elements overlap with Social History, but believe there is value in capturing these additional data elements as a separate Family History section, based on research on work disability risk. We have developed a Review of Systems template to capture the elements critical for work disability risk.
Elements of the History
History of the Present Illness (HPI)
What was injured? Where does it hurt? For illness, what system is involved?
Describe impact on activities at work or outside of work; consider using function scale; impact on activities of daily living
When was the onset? When are the symptoms worse or better
What makes it better or worse? How has the patient modified activities due to the condition?
Describe the character of the pain or other symptoms
How long have the symptoms lasted? If episodic, how long do they last when they occur?
How did the injury or condition occur? Describe circumstances if work injury, work factors if gradual onset attributed to work, protective equipment.
Other symptoms that may be related
Level of History
The same criteria used by CMS are used for workers’ compensation care, to establish the level of medical history.
Review of Systems
A complete Review of Systems (ROS) is an established requirement for a comprehensive history in most systems, and has been modified to provide useful information in workers’ compensation encounters. A template can be downloaded here.