MEDICAL ASSESSMENT FORM (FORM B) - GUIDELINES FOR MEDICAL PRACTITIONERS
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1 MEDICAL ASSESSMENT FORM (FORM B) - GUIDELINES FOR MEDICAL PRACTITIONERS The Personal Injuries Assessment Board is an independent statutory body. Our objective is to ensure that people claiming for injuries sustained in an accident, have their compensation assessed quickly and fairly and without unnecessary litigation overheads. The claimant must submit a report from their treating medical practitioner for us to assess their claim. Please note a copy of the medical report will be passed to the respondent/s (the person/s against whom the claim is being made) and their insurers where known, in order that they may know the nature and extent of the claim. As a result the medical report should only contain medical history relevant to the claim being made. We have undertaken to have the majority of claims assessed within nine months of submission and with this time frame in mind, it is vital that your report adheres to the following guidelines; is clear, concise and gives, as far as possible, a final prognosis and likely recovery period. Reports should be submitted in a standard format as per the attached template (ideally typed but in block capitals / easily legible at a minimum) be as clear and concise as possible contain an opinion/prognosis and your view on the likely recovery time for the claimant s injuries to resolve. If a full recovery is unlikely, outline the residual symptoms likely to be suffered by the claimant and what effect these will have on their lifestyle/work include relevant details of the claimant s medical and accident history and advise whether the accident has exacerbated any pre-existing symptoms/injury only include medical history/information relating to the claimant (and not about any third party) include good quality photographs where appropriate or requested Where a final prognosis is not currently available we may arrange a further up to date examination of the claimant. If the claim proceeds to assessment, the claimant may be awarded the reasonable and necessary cost of this medical report. Failure to furnish an adequate report may result in exceptional cases, in this amount not being awarded in full or at all.
2 MEDICAL ASSESSMENT FORM (FORM B) Application number (if available) Claimant name Address Gender Marital status Date of birth Occupation Currently at work Yes No Height Weight R/L hand dominant Date of accident Date of examination Brief details of the accident/incident Injuries sustained including diagnostic information Date treatment first sought From whom was treatment received? Was patient hospitalised Where was patient hospitalised Period of hospitalisation Length of absence from work If absence is on-going is it due to the accident? Was/is the claimant s absence period reasonable Number of GP visits Number of specialists visits, if any Identity of specialists, if any
3 Treatment/investigations to date Number of physiotherapy sessions, if any WHO International classification of diseases (ICD) Relevant medical history (including previous and subsequent accidents and clarification on any interaction of injuries) Aggravation of preexisting condition? Yes No If yes please give nature of preexisting condition Give details of previous accident history, if any Was pre-existing condition symptomatic before accident? Present complaints
4 Clinical findings on examination (please include photographs if appropriate or requested) Clinical description of effects on claimant s illness/disablement practitioners should indicate the degree, if any, to which the claimant s condition is currently affecting his/her ability in the following Mental health Normal Mild Moderate Severe Profound Learning/intelligence Consciousness/seiz ures Balance/coordination Vision Hearing Speech Continence Reaching Manual dexterity Lifting/carrying Bending/squatting Sitting Standing Climbing stairs Walking Anticipated treatment required into the future to include approximate costs
5 Opinion/comment/latest prognosis Are the injuries consistent with the accident? If not please specify Are further investigations required? If so please specify Is a full recovery expected? If not please detail likely effects on lifestyle/work Please state the expected time period to full recovery (from the date of accident) Are late complications expected? If so please specify Are further specialist reports recommended? If so please specify General comments and observations
6 Completed by: Practitioner signature and name: Address: Qualifications: Date of completion:
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