Medical Injury Report Template: Care Details & Signatures

Medical Injury Report Template

[Clinic / Hospital / Practice Name]

[Street Address]

[City, State/Province, ZIP/Postal Code]

Phone: [Phone Number]

Fax: [Fax Number]

Email: [Email Address]

1. Patient Identification

Patient Full Name: [First, Middle, Last]

Date of Birth: [MM/DD/YYYY]

Age: [Age]

Gender: [Gender]

Medical Record / Chart Number (if applicable): [Number]

Home Address:

[Street Address]

[City, State/Province, ZIP/Postal Code]

Phone Number: [Phone Number]

Email Address: [Email Address]

2. Visit and Provider Information

Date of Examination: [MM/DD/YYYY]

Time of Examination: [HH:MM a.m./p.m.]

Location of Examination: [Clinic / Emergency Department / Urgent Care / Occupational Health / Other]

Evaluating Provider Name: [Full Name]

Professional Title and Credentials: [e.g., MD, DO, NP, PA]

Specialty: [e.g., Emergency Medicine, Orthopedics, Family Medicine]

Referring Provider or Facility (if any): [Name / Facility / Contact]

3. Reason for Visit and Injury Overview

Chief Complaint (patient’s own words if possible):

[Example: “Right shoulder pain after fall at work,” “Neck and back pain after car accident,” etc.]

Type of Incident (check or describe):

• Motor vehicle accident (may include DUI-related)

• Workplace injury

• Slip-and-fall / trip-and-fall

• Sports / recreational injury

• Assault or violence

• Home / non-occupational incident

• Other: [Describe]

Motor vehicle accident (may include DUI-related)

Workplace injury

Slip-and-fall / trip-and-fall

Sports / recreational injury

Assault or violence

Home / non-occupational incident

Other: [Describe]

Date of Injury: [MM/DD/YYYY]

Approximate Time of Injury: [HH:MM a.m./p.m.]

Location of Injury (city, setting): [e.g., “Warehouse at employer,” “Public roadway,” “Home,” “Sports field”]

4. History of Present Injury (As Reported by Patient)

Brief Description of Incident:

[Free-text narrative, for example: “Patient reports that on [date], while [activity], they slipped and fell on [surface] landing on [body part].”]

Mechanism of Injury (check all that apply and describe):

• Fall from height / fall on same level – [Description]

• Motor vehicle collision – [Driver / passenger / pedestrian; front/side/rear impact; seatbelt/airbag use]

• Struck by object – [Description]

• Caught in / between equipment – [Description]

• Overexertion / lifting / repetitive motion – [Description]

• Assault – [Description, non-confidential summary]

• Other: [Describe]

Fall from height / fall on same level – [Description]

Motor vehicle collision – [Driver / passenger / pedestrian; front/side/rear impact; seatbelt/airbag use]

Struck by object – [Description]

Caught in / between equipment – [Description]

Overexertion / lifting / repetitive motion – [Description]

Assault – [Description, non-confidential summary]

Immediate Symptoms After Injury (patient report):

[Example: pain, swelling, dizziness, loss of consciousness, numbness, weakness, etc.]

Was there any loss of consciousness? [Yes / No / Unknown]

If Yes, estimated duration: [Approximate time]

Previous injuries or conditions to the same body part(s)? [Yes / No]

If Yes, brief description and approximate dates:

[Free-text]

5. Injured Body Parts and Reported Symptoms

Body Part(s) Involved (check or list):

• Head / Scalp

• Face / Eye / Nose / Mouth

• Neck / Cervical spine

• Shoulder / Arm / Elbow / Forearm / Wrist / Hand

• Chest / Ribs

• Thoracic / Lumbar spine (mid / low back)

• Abdomen / Pelvis

• Hip / Thigh

• Knee / Lower leg / Shin

• Ankle / Foot / Toes

• Other: [Describe]

Head / Scalp

Face / Eye / Nose / Mouth

Neck / Cervical spine

Shoulder / Arm / Elbow / Forearm / Wrist / Hand

Chest / Ribs

Thoracic / Lumbar spine (mid / low back)

Abdomen / Pelvis

Hip / Thigh

Knee / Lower leg / Shin

Ankle / Foot / Toes

Side of Body: [Left / Right / Both / Midline / Unknown]

Patient’s Reported Symptoms (use patient’s words when possible):

[Free-text: type and location of pain, stiffness, swelling, numbness, tingling, weakness, headache, visual changes, dizziness, etc.]

Pain Level (0–10 scale; 0 = no pain, 10 = worst imaginable):

Current Pain Score: [0–10]

Worst Pain Since Injury: [0–10]

Pain Character (sharp, dull, aching, burning, throbbing, etc.): [Description]

6. Vital Signs (If Obtained)

Date and Time Taken: [MM/DD/YYYY – HH:MM a.m./p.m.]

Blood Pressure: [___ / ___ mmHg]

Heart Rate (pulse): [***] beats/min

Respiratory Rate: [***] breaths/min

Temperature: [___ °F / °C]

Oxygen Saturation (SpO₂): [___ %]

Level of Consciousness: [Alert / Drowsy / Confused / Other]

7. Physical Examination Findings

General Appearance:

[Example: “Alert, in mild/moderate/severe distress,” “Well appearing,” etc.]

Head and Neck:

[Findings: tenderness, deformity, bruising, lacerations, range of motion, neurological signs, etc.]

Spine and Back:

[Findings: tenderness along spine or paraspinal muscles, range of motion, step-offs, spasm, etc.]

Upper Extremities (shoulder, arm, elbow, wrist, hand):

[Findings: swelling, bruising, deformity, range of motion, strength, sensation, pulses, special tests.]

Lower Extremities (hip, leg, knee, ankle, foot):

[Findings: swelling, bruising, deformity, range of motion, weight-bearing ability, strength, sensation, pulses.]

Neurological Exam (as applicable):

[Findings: orientation, cranial nerves if checked, motor strength, sensation, reflexes, gait, coordination.]

Skin and Soft Tissues:

[Findings: abrasions, lacerations, contusions, open wounds, signs of infection.]

Other Pertinent Findings:

[Free-text]

8. Diagnostic Tests

Tests Performed During This Visit (check and describe):

• X-ray – [Body part, date, key findings or “pending”]

• CT scan – [Area, date, key findings or “pending”]

• MRI – [Area, date, key findings or “pending”]

• Ultrasound – [Area, date, key findings or “pending”]

• Laboratory tests – [Type and brief results, if relevant]

• Other: [Describe]

X-ray – [Body part, date, key findings or “pending”]

CT scan – [Area, date, key findings or “pending”]

MRI – [Area, date, key findings or “pending”]

Ultrasound – [Area, date, key findings or “pending”]

Laboratory tests – [Type and brief results, if relevant]

Summary of Diagnostic Findings (if available):

[Brief narrative summary relevant to the injury.]

9. Diagnosis / Impression

Working Diagnosis / Clinical Impression (list all that apply):

1. [Primary injury diagnosis, e.g., “Right ankle sprain”]

2. [Secondary injury or condition]

3. [Other relevant conditions]

[Primary injury diagnosis, e.g., “Right ankle sprain”]

[Secondary injury or condition]

[Other relevant conditions]

ICD-10 or other codes (optional):

[Codes, if used]

10. Treatment Provided at This Visit

Treatment and Interventions (check and describe):

• Wound care (cleaning, closure, dressing) – [Details]

• Immobilization (splint, cast, brace, sling) – [Details]

• Medications administered in facility – [Name, dose, route]

• Prescriptions given – [Medication name, dose, frequency, duration]

• Injections (e.g., local anesthetic, steroid) – [Details]

• Physical therapy or rehabilitation referral – [Details]

• Specialist referral (e.g., orthopedics, neurology, pain management) – [Details]

• Imaging or additional tests ordered – [Details]

• Patient education and home care instructions – [Brief description]

• Other: [Describe]

Wound care (cleaning, closure, dressing) – [Details]

Immobilization (splint, cast, brace, sling) – [Details]

Medications administered in facility – [Name, dose, route]

Prescriptions given – [Medication name, dose, frequency, duration]

Injections (e.g., local anesthetic, steroid) – [Details]

Physical therapy or rehabilitation referral – [Details]

Specialist referral (e.g., orthopedics, neurology, pain management) – [Details]

Imaging or additional tests ordered – [Details]

Patient education and home care instructions – [Brief description]

11. Activity, Work, and Driving Restrictions

Based on today’s evaluation, the patient is:

• Cleared for normal activities as tolerated.

• Cleared for limited activities with restrictions as below.

• Temporarily not fit for work / school from [Start Date] to [End Date or “Until re-evaluated”].

Cleared for normal activities as tolerated.

Cleared for limited activities with restrictions as below.

Temporarily not fit for work / school from [Start Date] to [End Date or “Until re-evaluated”].

Recommended Restrictions (check and specify as appropriate):

• No lifting over [] lbs / [] kg.

• No prolonged standing or walking (limit to [___] minutes at a time).

• No climbing ladders or working at heights.

• No driving or operating heavy machinery until [Date] or until cleared.

• Seated work only, with ability to change positions as needed.

• No sports or strenuous physical activity.

• Other: [Describe]

No lifting over [] lbs / [] kg.

No prolonged standing or walking (limit to [___] minutes at a time).

No climbing ladders or working at heights.

No driving or operating heavy machinery until [Date] or until cleared.

Seated work only, with ability to change positions as needed.

No sports or strenuous physical activity.

Estimated Duration of Restrictions (subject to change with recovery):

• Less than 1 week

• 1–4 weeks

• 4–8 weeks

• More than 8 weeks

• To be determined at follow-up

Less than 1 week

1–4 weeks

4–8 weeks

More than 8 weeks

To be determined at follow-up

12. Follow-Up Plan

Recommended Follow-Up:

• Return to this clinic in [__] days/weeks.

• Follow up with primary care provider by [Date].

• Follow up with specialist (type and timeframe): [Details]

• Return sooner or go to ER for worsening symptoms such as [e.g., increasing pain, weakness, numbness, shortness of breath, chest pain, severe headache, repeated vomiting, confusion].

Return to this clinic in [__] days/weeks.

Follow up with primary care provider by [Date].

Follow up with specialist (type and timeframe): [Details]

Return sooner or go to ER for worsening symptoms such as [e.g., increasing pain, weakness, numbness, shortness of breath, chest pain, severe headache, repeated vomiting, confusion].

Additional Instructions Given to Patient:

[Free-text summary of discharge and self-care instructions.]

13. Notifications and Coordination (If Applicable)

Was employer, insurer, or another party notified from this visit?

• Employer / Occupational Health

• Workers’ compensation insurer

• Liability or auto insurer

• Case manager

• Attorney (with patient authorization)

• Other: [Describe]

Employer / Occupational Health

Workers’ compensation insurer

Liability or auto insurer

Case manager

Attorney (with patient authorization)

Details (names, dates, and method of communication, if documented):

[Free-text]

14. Provider Certification and Signature

I, [Provider Full Name], certify that this Medical Injury Report is based on my examination of the patient and available information as of the date noted. It is intended to describe the patient’s injuries, clinical findings, and treatment plan and does not, by itself, determine legal fault or liability.

Provider Signature: _______________________________

Printed Name: [Provider Full Name, Credentials]

License Number: [Number]

Licensing State/Province: [State/Province]

Date: [MM/DD/YYYY]

Optional Stamp or Seal:

[Space for provider or facility stamp]