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Extent of Injury Analysis Section of a Designated Doctor Report
In addition to the basic requirements of a designated doctor narrative report in 28 TAC Rule
127.220, a narrative on extent of injury may include the following information:
I. Injury in Question (Box 36C of the DWC Form-032)
State injuries in question as listed in Box 36C, and define and describe each injury in medical terms.
Note: Extent of Injury is a specific question as to a specific injury as listed in Box 36C. Failure to use the exact terms aslisted in Box 36C to refer to the injury may result in a letter of clarification, or a report not being adopted. If there areother medical terms used in the report to refer to the injury in question as listed in Box 36C, explain or clarify that to thereader by stating these terms are synonyms, one is inclusive of the other, etc. If there are injuries that can be groupedtogether as the same, or part of the same medical process, explain such grouping.
ii. Accident/Incident (Mechanism of Injury)
Describe the accident/incident (mechanism of injury). Include any account described and who gave it. (i.e.Claimant told me during the exam, or treating doctor describes in the notes on 1/1/2018.)
Ill. Clinical Findings and Timeline in Support of Causation Analysis
Provide the relevant findings contained in the medical records, history and physical exam. Where applicable,detail symptom onset relative to the timeline of the medical history.
In your review and detail of the above, pay particular attention to the following in relation to the injury in question (Box36C):
a. Did the injury in question exist prior to the work-related accident or incident (mechanism of injury)?b. Was the injury in question present during the physical examination?
IV. Analysis of Clinical Findings and Timeline
Provide an analysis based on the findings from Sections II and ill above, and any other relevant supportingfactors to explain the basis for the opinion regarding the injury in question (Box 36C).
Pay particular attention to the following in relation to the causation analysis for the injury in question (Box 36C), andexplain all that are applicable:
a. Consider whether the timeline of symptom onset was consistent with the work-related injury, including relevantmedical records prior to the injury, proximate to the time of injury, as well as post-injury treatment and testing.
b. Is this type of work-related accident/incident (mechanism of injury) consistent or inconsistent with the injury inquestion?
If evidence-based medicine is available, then explain how it supports that the work-related accident/ incident (mechanismof injury) caused or did not cause the injury in question (Box 36C).
v. Medical/Legal Causation Opinion Statement
SAMPLE CONCLUSION TEXT“Based on the above referenced reasons, it is my medical opinion, based upon my education, training, and experience,and within reasonable medical probability that (the work-related accident/incident! mechanism of injury) caused or didnot cause the injury in question (Box 36C). I find that the compensable injury of (mm/dd/yyyy) was! was not a substantialfactor in bringing about the additional claimed injury or condition (Box 36C), and without it, the additional injury orcondition (Box 36C) would not have occurred. Specifically, it does or does not extend to include (Box 36C).”
**DWC does not require use of this form, and additionally, this form is not applicable in all cases. DDs must adhere to all applicable rulesregarding reporting requirements and this form is neither a substitute nor an addendum to those requirements. This form is an exampleof expert causation analysis where extent of injury is an issue, and is not a comment on whether expert testimony is required to establishcausation as to this, or any other specific injury. Whether expert testimony is required to establish causation for an injury is adetermination that is made at the hearings level on a case by case basis.
DWC Sample without EBM for
Extent of Injury Analysis Section of DD Report
I. Injury in Question
A lateral malleolus fracture is a fracture of the distal fibula, also referred to synonymously in the medical recordsas
_____________
II. Accident/Injuryf Mechanism of Injury)
As stated in the E.R. records, the injured employee stepped off a curb while at work in the Metro Center ParkingLot on March 15, 2017. According to the injured employee’s account, which was given shortly after the accidentand further explained to me during the exam, he “missed the ground” and twisted his ankle, falling on his rightside.
Ill. Clinical Findings, Timeline and Literature in Support of Causation Analysis
There is no reference in the medical records, and the injured employee specifically denies ever having had anyinjury or any treatment to the right ankle prior to the accident on March 15, 2017.
X-rays on March 15, 2017, clearly documented an acute fracture of the right lateral malleolus. Subsequent xrays dated December 17, 2017, demonstrate a healed fracture of the right lateral malleolus. Although anunhealed fracture is not present upon my exam, both my exam and the medical records indicate a priorunhealed fracture of the right lateral malleolus was present immediately after the fall on March 15, 2017. Thatfracture resolved! healed prior to my exam of the injured employee.
Based on the E.R. records, the injured employee was seen at the emergency room shortly after his fall anddiagnosed with a fracture of his right hip. The right hip fracture is not the injury question. The injuredemployee also complained at the emergency room of sudden and severe pain in his right ankle upon falling.Within an hour of the injury, the injured employee had significant swelling and bruising of his right ankle, andthe ankle was tender to the touch. It is an unknown if the employee was able to bear weight on the ankle, as hiship fracture prevented him from walking. The symptoms of the fracture of the right lateral malleolus appearedimmediately following the injury, which is when you would expect to see such symptoms appear if a sprain orfracture did exist as a result of the fall. X-rays taken within two hours of the injury revealed a fracture on thelower part of the right lateral malleolus.
IV. Analysis of Clinical Findings and Timeline:
Based on the findings that the injured employee had significant swelling and bruising of his right ankle, thesymptoms of the fracture of the right lateral malleolus appeared immediately following the injury, and x-raystaken within two hours of the injury revealed a fracture on the lower part of the right lateral malleolus, Iconclude that the timing of the fracture of the right lateral malleolus is consistent with the fall on March 15,
** DWC does not require use of this form, and additionally, that this form is not applicable in all cases. DDs must adhereto all applicable rules regarding reporting requirements and this form is neither a substitute nor an addendum to thoserequirements.
2017. The proximity in time of the symptom onset and positive films indicating a fracture to the right lateralmalleolus indicate that the fall on March 15, 2017 caused the fracture of the right lateral malleolus.
As previously stated, the lack of any medical documentation, and the specific denial by the injured employee,support that there was no fracture to the right lateral malleolus prior to the fall on March 15, 2017. This lendsfurther support to my opinion that the fall was the cause of the injury in question, because had the injury inquestion been present prior to the fall on March 15, 2017, it is reasonable that there would be medical recordsevidencing a fracture of the right lateral malleolus and treatment for same that pre-date March 15, 2017.
Further, the mechanism of injury—falling off a curb and twisting his ankle—is consistent with the fracture of theright lateral malleolus. Twisting the ankle while falling and putting weight on the joint from the height of a curbcaused torquing forces to the injured employee’s right ankle joint, which stressed and exceeded the strength ofthe joint structures of his right ankle and produced the fracture of the right lateral malleolus.
V. Medical/Legal Causation Opinion Statement
For the above referenced reasons; the relevant clinical and exam findings, the relevant medical history, thesymptom timeline, and the mechanism of injury as described above, it is my medical opinion, based upon myeducation, training, and experience, and within reasonable medical probability that stepping off of the curb andtwisting the right ankle caused the fracture of the right lateral malleolus. I find that the mechanism of injury ofMarch 15, 2017 was a substantial factor in bringing about the fracture of the right lateral malleolus, and withoutit, the fracture of the right lateral malleolus would not have occurred. Specifically, the compensable injuryextends to and includes the fracture of the right lateral malleolus.
** DWC does not require use of this form, and additionally, that this form is not applicable in all cases. DDs must adhereto all applicable rules regarding reporting requirements and this form is neither a substitute nor an addendum to thoserequirements.
Exte
nt
of
Inju
ryA
naly
sis
Sec
tion
of
aD
esig
nat
edD
oct
or
Rep
ort
Inad
diti
onto
the
basi
cre
quir
emen
tsof
ade
sign
ated
doct
orna
rrat
ive
repo
rtin
28
TA
CR
ule
127.220,
anarrative
on
ex
ten
tof
in
ju
ry
may
include
the
follow
ing
inform
ation:
I.In
jury
inQ
ues
tion
(Box
36C
ofth
eD
WC
For
m-0
32)
Con
side
rati
ons
DW
CS
ampl
eR
epor
t Lan
guag
e
_________
__
__
__
__
__
__
__
__
__
__
__
__
___
__
__
__
__
__
__
__
__
__
__
__
__
__
__
(Exa
mpl
ew
ithout
EB
M)
Sta
tein
juri
esin
ques
tion
asli
sted
inB
ox36
C,
and
defi
nean
dde
scri
beA
late
ral
mal
leol
usfr
actu
reis
afr
actu
reof
the
dist
alfi
bula
,al
sore
ferr
edto
each
inju
ryin
med
ical
term
s.sy
nony
mou
sly
inth
em
edic
alre
cord
sas
___________
Not
e:E
xten
tof
Inju
ryis
asp
ecif
icqu
esti
onas
toa
spec
ific
inju
ryas
liste
din
Box
36C
.Fa
ilure
tous
eth
eex
act
term
sas
list
edin
Box
36C
tore
fer
toth
ein
jury
may
resu
ltin
ale
tter
ofcl
arif
icat
ion,
ora
repo
rtno
tbe
ing
adop
ted.
Ifth
ere
are
oth
erm
edic
alte
rms
used
inth
ere
port
tore
fer
toth
ein
jury
inqu
esti
onas
list
edin
Box
36C
,ex
plai
nor
clar
ify
that
toth
ere
ader
byst
atin
gth
ese
term
sar
esy
nony
ms,
one
isin
clus
ive
ofth
eot
her,
etc.
Ifth
ere
are
inju
ries
that
can
begr
oupe
dto
get
her
asth
esa
me,
orpa
rtof
the
sam
em
edic
alpr
oces
s,ex
plai
nsu
chgr
oupi
ng.
u.A
ccid
ent/
Inci
den
t(M
echan
ism
of
Inju
ry)
Con
side
rati
ons
DW
CS
ampl
eR
epor
t Lan
guag
e(E
xam
ple
wit
ho
ut
EB
M)
Des
crib
eth
eac
cide
nt/i
ncid
ent
(mec
hani
smof
inju
ry).
Incl
ude
any
As
stat
edin
the
E.R
.re
cord
s,th
ein
jure
dem
ploy
eest
eppe
dof
fa
curb
whi
leat
account
des
crib
edan
dw
hogave
it.
(i.e
.C
laim
ant
told
me
duri
ngth
ew
ork
inth
eM
etro
Cen
ter
Par
king
Lot
onM
arch
15,
2017
.A
ccor
ding
toth
e
exam
,or
treating
doct
or
des
crib
esin
the
notes
on
1/1
/2018.)
inju
red
empl
oyee
’sac
coun
t,w
hich
was
give
nsh
ortl
yaf
ter
the
acci
dent
and
furt
her
expl
aine
dto
me
duri
ngth
eex
am,
he“m
isse
dth
egr
ound
”an
dtw
iste
dhi
san
kle,
fall
ing
onhi
sri
ght
side
.
**D
wc
does
not
requ
ire
use
ofth
isfo
rm,
and
addi
tion
ally
,th
atth
isfo
rmis
not
appl
icab
lein
all
case
s.D
Ds
mus
tad
here
toal
lap
plic
able
rule
sre
gard
ing
repo
rtin
gre
quir
emen
tsan
dth
isfo
rmis
neit
her
asu
bsti
tute
nor
anad
dend
umto
thos
ere
quir
emen
ts.
Thi
sfo
rmis
anex
ampl
eof
expe
rtca
usat
ion
anal
ysis
whe
reex
tent
ofin
jury
isan
issu
e,an
dis
not
aco
mm
ent
onw
heth
erex
pert
test
imon
yis
recj
uire
dto
esta
blis
hca
usat
ion
asto
this
,or
any
othe
rsp
ecif
icin
jury
.W
heth
erex
pert
test
imon
yis
requ
ired
toes
tabl
ish
caus
atio
nfo
ran
inju
ryis
ade
term
inat
ion
that
ism
ade
atth
ehe
arin
gsle
vel
ona
case
byca
seba
sis.
Ill.
Clin
ical
Findings
an
dT
im
eline
in
Support
of
Causation
Analysis
Con
side
rati
ons
DW
CS
ampl
eR
epor
tLan
guag
e(E
xam
ple
_w
ith
ou
tEB
M)
Pro
vide
the
rele
van
tfin
ding
sco
nta
ined
inth
em
edic
alre
cord
s,T
here
isno
refe
renc
ein
the
med
ical
reco
rds,
and
the
inju
red
empl
oyee
hist
ory
and
phys
ical
exam
.W
here
appl
icab
le,
det
ails
ympt
omo
nse
tsp
ecif
ical
lyde
nies
ever
havi
ngha
dan
yin
jury
oran
ytr
eatm
ent
toth
eri
ght
ankl
epr
ior
toth
eac
cide
nton
Mar
ch15
,20
17.
rela
tive
toth
eti
mel
ine
of
the
med
ical
hist
ory.
Inyo
urre
view
and
deta
ilof
the
abov
e,pa
ypa
rtic
ular
atte
nti
on
toth
eX
-ray
son
Mar
ch15
,20
17,
clea
rly
docu
men
ted
anac
ute
frac
ture
ofth
eri
ght
foll
owin
gin
rela
tion
toth
ein
jury
inqu
esti
on(B
ox36
C):
late
ral
mal
leol
us.
Sub
sequ
ent
x-ra
ysda
ted
Dec
embe
r17
,20
17,
dem
onst
rate
ahe
aled
frac
ture
of
the
righ
tla
tera
lm
alle
olus
.A
ltho
ugh
anun
heal
edfr
actu
reis
a.D
idth
ein
jury
inqu
esti
onex
ist
prio
rto
the
wor
k-re
late
dac
cide
ntor
not
pres
ent
upon
my
exam
,bo
thm
yex
aman
dth
em
edic
alre
cord
sin
dica
tea
inci
dent
(mec
hani
smof
inju
ry)?
prio
run
heal
edfr
actu
reof
the
righ
tla
tera
lm
alle
olus
was
pres
ent
imm
edia
tely
afte
rth
efa
llon
Mar
ch15
,20
17.
Tha
tfr
actu
rere
solv
ed/h
eale
dpr
ior
tom
yex
amb.
Was
the
inju
ryin
ques
tion
pres
ent
duri
ngth
eph
ysic
alex
amin
atio
n?of
the
inju
red
empl
oyee
.
Bas
edon
the
E.R
.re
cord
s,th
ein
jure
dem
ploy
eew
asse
enat
the
emer
genc
yro
omsh
ortl
yaf
ter
his
fall
and
diag
nose
dw
itha
frac
ture
ofhi
sri
ght
hip.
The
righ
thi
pfr
actu
reis
not
the
inju
ryin
ques
tion
.T
hein
jure
dem
ploy
eeal
soco
mpl
aine
dat
the
emer
genc
yro
omof
sudd
enan
dse
vere
pain
inhi
sri
ght
ankl
eup
onfa
llin
g.W
ithi
nan
hour
ofth
ein
jury
,th
ein
jure
dem
ploy
eeha
dsi
gnif
ican
tsw
elli
ngan
dbr
uisi
ngof
his
righ
tan
kle,
and
the
ankl
ew
aste
nder
toth
eto
uch.
Itis
anun
know
nif
the
empl
oyee
was
able
tobe
arw
eigh
ton
the
ankl
e,as
his
hip
frac
ture
prev
ente
dhi
mfr
omw
alki
ng.
The
sym
ptom
sof
the
frac
ture
ofth
eri
ght
late
ral
mal
leol
usap
pear
edim
med
iate
lyfo
llow
ing
the
inju
ry,
whi
chis
whe
nyo
uw
ould
expe
ctto
see
such
sym
ptom
sap
pear
ifa
spra
inor
frac
ture
did
exis
tas
are
sult
ofth
efa
ll.X
-ray
sta
ken
wit
hin
two
hour
sof
the
inju
ryre
veal
eda
frac
ture
onth
elo
wer
part
ofth
eri
ght
late
ral
mal
leol
us.
IV.
Ana
lysi
sof
Clin
ical
Fin
ding
san
dT
imel
ine
Con
side
rati
ons
DW
CS
ampl
eR
epor
tL
angu
age
(Exa
mpl
e_w
itho
utE
BM
)
Pro
vide
anan
alys
isbas
edon
the
find
ings
from
Sec
tion
sII
and
Bas
edon
the
find
ings
that
the
inju
red
empl
oyee
had
sign
ific
ant
swel
ling
and
abov
e,an
dan
yoth
erre
levan
tsupport
ing
fact
ors
toex
plai
nth
eba
sis
brui
sing
ofhi
sri
ght
ankl
e,th
esy
mpt
oms
ofth
efr
actu
reof
the
righ
tla
tera
l
for
the
opin
ion
reg
ard
ing
the
inju
ryin
ques
tion
(Box
36C
).m
alle
olus
appe
ared
inim
edia
tely
foll
owin
gth
ein
jury
,an
dx-
rays
take
nw
ithi
n
**D
wc
does
not
requ
ire
use
ofth
isfo
rm,
and
addi
tion
ally
,th
atth
isfo
rmis
not
appl
icab
lein
all
case
s.D
Ds
mus
tad
here
toal
lap
plic
able
rule
sre
gard
ing
repo
rtin
gre
quir
emen
tsan
dth
is
form
isne
ithe
ra
subs
titu
teno
ran
adde
ndum
toth
ose
requ
irem
ents
.T
his
form
isan
exam
ple
ofex
pert
caus
atio
nan
alys
isw
here
exte
ntof
inju
ryis
anis
sue,
and
isno
ta
com
men
ton
whe
ther
expe
rtte
stim
ony
isre
quir
edto
esta
blis
hca
usat
ion
asto
this
,or
any
othe
rsp
ecif
icin
jury
.W
heth
erex
pert
test
imon
yis
requ
ired
toes
tabl
ish
caus
atio
nfo
ran
inju
ryis
ade
term
inat
ion
that
ism
ade
atth
ehe
arin
gsle
vel
ona
case
byca
seba
sis.
Pay
part
icul
arat
tenti
on
toth
efo
llow
ing
inre
lati
onto
the
caus
atio
nan
alys
isfo
rth
ein
jury
inqu
esti
on(B
ox36
C),
and
expl
ain
all
that
are
appl
icab
le:
a.C
onsi
der
whet
her
the
tim
elin
eof
sym
ptom
onse
tw
asco
nsis
tent
wit
hth
ew
ork-
rela
ted
inju
ry,
incl
udin
gre
leva
ntm
edic
alre
cord
spr
ior
toth
ein
jury
,pr
oxim
ate
toth
eti
me
ofin
jury
,as
wel
las
post
-inj
ury
trea
tmen
tan
dte
stin
g.b.
Isth
isty
peof
wor
k-re
late
dac
cide
nt/i
ncid
ent
(mec
hani
smof
inju
ry)
cons
iste
ntor
inco
nsis
tent
wit
hth
ein
jury
inqu
esti
on?
c.If
evid
ence
-bas
edm
edic
ine
isap
plic
able
,th
enex
plai
nho
wit
supp
orts
that
the
wor
k-re
late
dac
cide
nt!
inci
dent
(mec
hani
smof
inju
ry)
caus
edor
did
not
caus
eth
ein
jury
inqu
esti
on(B
ox36
C).
two
hour
sof
the
inju
ryre
veal
eda
frac
ture
onth
elo
wer
part
ofth
eri
ght
late
ral
mal
leol
us,
Ico
nclu
deth
atth
eti
min
gof
the
frac
ture
ofth
eri
ght
late
ral
mal
leol
usis
cons
iste
ntw
ithth
efa
llon
Mar
ch15
,20
17.
The
prox
imit
yin
tim
eof
the
sym
ptom
onse
tan
dpo
siti
vefi
lms
indi
cati
nga
frac
ture
toth
eri
ght
late
ral
mal
leol
usin
dica
teth
atth
efa
llon
Mar
ch15
,20
17ca
used
the
frac
ture
ofth
eri
ght
late
ral
mal
leol
us.
As
prev
ious
lyst
ated
,th
ela
ckof
any
med
ical
docu
men
tati
on,
and
the
spec
ific
deni
alby
the
inju
red
empl
oyee
,su
ppor
tth
atth
ere
was
nofr
actu
reto
the
righ
tla
tera
lm
al[e
olus
prio
rto
the
fall
onM
arch
15,
2017
.T
his
lend
sfu
rthe
rsu
ppor
tto
my
opin
ion
that
the
fall
was
the
caus
eof
the
inju
ryin
ques
tion
,be
caus
eha
dth
ein
jury
inqu
esti
onbe
enpr
esen
tpr
ior
toth
efa
llon
Mar
ch15
,20
17,
itis
reas
onab
leth
atth
ere
wou
ldbe
med
ical
reco
rds
evid
enci
nga
frac
ture
ofth
eri
ght
late
ral
mal
leol
usan
dtr
eatm
ent
for
sam
eth
atpr
e-da
teM
arch
15,
2017
.
Fur
ther
,th
em
echa
nism
ofin
jury
—fa
llin
gof
fa
curb
and
twis
ting
his
ankl
e—is
cons
iste
ntw
ith
the
frac
ture
ofth
eri
ght
late
ral
mal
leol
us.
Tw
isti
ngth
ean
kle
whi
lefa
llin
gan
dpu
ttin
gw
eigh
ton
the
join
tfr
omth
ehe
ight
ofa
curb
caus
edto
rqui
ngfo
rces
toth
ein
jure
dem
ploy
ee’s
righ
tan
kle
join
t,w
hich
stre
ssed
and
exce
eded
the
stre
ngth
ofth
ejo
int
stru
ctur
esof
his
righ
tan
kle
and
prod
uced
the
frac
ture
ofth
eri
ght
late
ral
mal
leol
us.
**D
WC
does
not
requ
ire
use
ofth
isfo
rm,
and
addi
tion
ally
,th
atth
isfo
rmis
not
appl
icab
lein
all
case
s.D
Ds
mus
tad
here
toal
lap
plic
able
rule
sre
gard
ing
repo
rtin
gre
quir
emen
tsan
dth
isfo
rmis
neit
her
asu
bsti
tute
nor
anad
dend
umto
thos
ere
quir
emen
ts.
Thi
sfo
rmis
anex
ampl
eof
expe
rtca
usat
ion
anal
ysis
whe
reex
tent
ofin
jury
isan
issu
e,an
dis
not
aco
mm
ent
onw
heth
erex
pert
test
imon
yis
requ
ired
toes
tabl
ish
caus
atio
nas
toth
is,
oran
yot
her
spec
ific
inju
ry.
Whe
ther
expe
rtte
stim
ony
isre
quir
edto
esta
blis
hca
usat
ion
for
anin
jury
isa
dete
rmin
atio
nth
atis
mad
eat
the
hear
ings
leve
lon
aca
seby
case
basi
s.
v.M
edic
al/L
egal
Cau
sati
on
Opi
nion
Sta
tem
ent
Co
nsid
eration
sD
WC
Sam
ple
Report
Language
(E
xam
ple
without
EB
M)
SA
MP
LE
CO
NC
LU
SIO
NT
EX
TF
orth
eab
ove
refe
renc
edre
ason
s;th
ere
leva
ntcl
inic
alan
dex
amfi
ndin
gs,
the
“Bas
edon
the
abov
ere
fere
nced
reas
ons,
itis
my
med
ical
opin
ion,
base
dre
leva
ntm
edic
alhi
stor
y,th
esy
mpt
omti
mel
ine,
and
the
mec
hani
smof
inju
ryas
upon
my
educ
atio
n,tr
aini
ng,
and
expe
rien
ce,
and
wit
hin
reas
onab
lem
edic
alde
scri
bed
abov
e,it
ism
ym
edic
alop
inio
n,ba
sed
upon
my
educ
atio
n,tr
aini
ng,
prob
abil
ity
that
(the
wor
k-re
late
dac
cide
nt/i
ncid
ent!
mec
hani
smof
inju
ry)
and
expe
rien
ce,
and
wit
hin
reas
onab
lem
edic
alpr
obab
ilit
yth
atst
eppi
ngof
fof
caus
edor
did
not
caus
eth
ein
jury
inqu
esti
on(B
ox36
C).
Ifin
dth
atth
eth
ecu
rban
dtw
isti
ngth
eri
ght
ankl
eca
used
the
frac
ture
ofth
eri
ght
late
ral
com
pens
able
inju
ryof
(mm
/’dd
/yyy
y)w
as!
was
not
asu
bsta
ntia
lfa
ctor
inm
alle
olus
.I
find
that
the
mec
hani
smof
inju
ryof
Mar
ch15
,20
17w
asa
brin
ging
about
the
addi
tion
alcl
aim
edin
jury
orco
ndit
ion
(Box
36C
),an
dsu
bsta
ntia
lfa
ctor
inbr
ingi
ngab
out
the
frac
ture
ofth
eri
ght
late
ral
mal
leol
us,
and
wit
hout
it,th
ead
diti
onal
inju
ryor
cond
itio
n(B
ox36
C)
wou
ldno
tha
vew
itho
utit,
the
frac
ture
ofth
eri
ght
late
ral
mal
leol
usw
ould
not
have
occu
rred
.
occu
rred
.Sp
ecif
ical
ly,
itdo
esor
does
not
exte
ndto
incl
ude
(Box
36C
).”S
peci
fica
lly,
the
com
pens
able
inju
ryex
tend
sto
and
incl
udes
the
frac
ture
ofth
eri
ght
late
ral
mal
leol
us.
Some Resources for Obtaining Evidence
1. Official Disability Guidelines (ODG) — “Causality” or “Causation” tab in relevant ProcedureSummary
2. Reed Group Disability Guidelines (MDGuidelines or Medical Disability Guidelines) “Risk andCausation” tab for relevant condition.
3. AMA Guides to the Evaluation of Disease and Injury Causation by Melhorn, Ta Image, Ackermanand Hyman 2nd Edition, 2013
4. Medline/PubMed: http://medlineplus.gov/
5. TRIP: Turning Research Into Practice: http://www.tripdatabase.com/index.html
6. Guidelines.gov: http://guidelines.gov
7. Medscape: http://www.medscape.com/
8. eMedicine /Medscape: http://emedicine.medscape.com/
9. Wheeless’ Textbook of Orthopedics Online: http://www.wheelessonline.com]10. JAMA: http://jama.jamanetwork.com/journal.aspx
11. Spine: http://www.spinejournal.com
12. The Spine Journal (NASS): http://www.thespinejournalonline.com/
13. Journal of Bone and Joint Surgery: http://ibis.org/
14. Journal of Orthopedic Research: http://www.ors.org/ journal-of-orthopaedic-research/15. Annals of Internal Medicine: http://www.annals.org/
16. American College of Radiology: http://www.acr.org/
17. British Journal of Medicine: http://www.bmi.com/
1$. Lancet: http://www.thelancet.com/
19. Centre for Evidenced Based Medicine: http://www.cebm .net/index.aspx?o=101120. Journal of Manipulative and Physiological Therapeutics: http://www.imptonline.org/
21. Journal of Family Practice: http://www.jfponline.com/
Library Resources
You may want to consider working with a reference librarian to help you obtain relevant evidence.Here’s a list of some library resources in Texas:
http:/Jnnlm .gov/scr/outreach/texas. html
Resource Libraries
Resource Libraries are major health sciences libraries selected by the NN/LM 5CR on the basis of thequality and size of collections or uniqueness of materials in their collections which add significantly tothe resources of the region.
• Houston Academy of Medicine-Texas Medical Center Library
• Texas A&M University Medical Sciences Library
• Texas Tech University Health Sciences Center, Libraries of the Health Sciences
• University of North Texas Health Science Center, Gibson D. Lewis Library
• University of Texas Health Science Center at San Antonio Library
• University of Texas M.D. Anderson Cancer Center Research Medical Library
• University of Texas Medical Branch Moody Medical Library
• University of Texas Southwestern Medical Center Library
Also:
• Texas Medical Association http://www.texmed.org/Ask A Librarian.aspx
Also see “How to order articles” handout about the National Library of Medicine’s Loansome
Doc (https://docline.gov/loansome/login.cfm) ordering system, which allows users to order fulltext copies of articles found in PubMed/MEDLINE® from a medical library (local fees anddelivery methods can vary).
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TEXAS DEPARTMENT OF INSURANCEDivision of Workers’ Compensation fMS-603)7551 Metro Center Drive, Suite 100, Austin, Texas 787444645
(512) 804-4010 I F: (512) 804-4011 I (800) 252-7031 I TDI.texas.gov I @TexasTDI
Presiding Officer’s Directive to Order Designated Doctor Exam
I. Injured Employee InformationEmployee Name Employee Address
Exam Type DWC # Sequence Employee SSNEJ Initial ERe-Exam -
Date of Birth Date of Injury Telephone Number
Does the claim involve medical benefits provided through a Certified Workers’ Compensation Health Care Network or apolitical subdivision pursuant to 504.053(b)(2) of the Texas Labor Code, relating to directly contracting with health careproviders or contracting through a health benefits pool? Yes El NoIf Yes, name of network or health care plan:
II. Other Contact InformationPhone Number Ext. Fax Number
Employee Representative or Assistant (OIEC) Name
Insurance Carrier/Adjuster Name
Insurance Carrier Rep Present at Hearing
Treating Doctor Name License Number License Type Phone Number
III. Reason for Exam (See Page 2, Section V. regarding Presiding Officer’s Specific Instructions for Examination)
Reason (check all that apply) Additional Information
LI A. Maximum Medical Improvement Statutory MMI Date (if any): (mm/dd/yyyy)
LI B. Impairment Rating MMI Date (Only if Box A of this section is Not Checked): (mm/dd/yyyy)
LI C. Extent of Injury Specific information should be included in Section V of this directive (page 2)
LI D. Disability — Direct Result Period to be assessed: From: to (mm/dd/yyyy) PresentEnding date cannot be a future date. Check “present”, if no specific ending date.
LI E. Return to Work Period to be assessed: From: to (mm/dd/yyyy) Present
LI F. Return to Work Period to be assessed: From: to (mm/dd/yyyy) Present(Supplemental Income Benefits) Is the above qualifying period applicable to the 9th quarter (or a subsequent
quarter) of supplemental income benefits? Yes Q No
LI G. Other similar issues Specific information should be included in Section V of this directive (page 2)
IV. Body Areas/Diagnoses to be Assessed by the Designated Doctorre-examination, should a new Designated Doctor be assjd? LI Yes fl No Current DD
LI Spine and Musculoskeletal Structures of Torso LI Spinal Cord Injury
LI Upper Extremities LI Severe Burns (including chemical burns)
Lower Extremities (excluding feet) LI Multiple Fractures, Joint Dislocation, Hip or Pelvis Fracture
LI Feet LI Infectious Diseases (complicated)
LI Teeth and Jaw Complex Regional Pain Syndrome
LI Eyes Chemical Exposure
LI Other Body Areas/Systems— LI Heart or Cardiovascular Condition
LI Traumatic Brain Injury LI Mental and Behavioral Disorders
HRG-04-TM-04 Directive to Order DD v.4.0 Page 1 of 2
Employee Name DWC # Seq Employee SSN Date of Birth Date of Injury
V. Presiding Officer’s Specific Instructions for Examination
Presiding Officer (Printed Name) Signature Date
HRG-04-TM-04 Directive to Order DD v.4.0 Page 2 of 2
Resource Type Version Website
Medline/PubMedDatabase bibliographic
FREE - Unfiltered http://medlineplus.gov/
Guidelines.gov Website FREE http://guidelines.govTRIP: Turning Research Into Practice
Website/ Database Oxford
FREE - Pre-filtered http://www.tripdatabase.com/index.html
Evidence based Medicine (BMJ)JournalWebsite
Subscription Print/Electronic
Annals of Internal Medicine JournalSubscription Print/ Electronic
http://www.annals.org
JAMA JournalSubscription Print/ Electronic
British Journal of Medicine JournalSubscription Print/ Electronic
Lancet JournalSubscription Print/ Electronic
Journal of Family Practice (JFP)
Journal;*POEMS *PURLS*Applied Evidence*Answers to Common
Clinical Questions
Suscription Print/ Electronic
http://www.jfponline.com
Bandolier Website FREE - Pre-filtered http://www.jr2.ox.ac.uk/Bandolier/
Spine JournalSubscription Print/ Electronic
http://www.spinejournal.com
Journal of Bone and JointSurgery (American)
JournalSubscription Print/ Electronic
American Journal of SportsMedicine
JournalSubscription Print/ Electronic
Rheumatology Website http://www.rheumatology.org/publications/primarycare/
Journal of Orthopaedic andSports Physical Therapy (JOSPT)
JournalSubscription Print/ Electronic
Journal of Clinical Outcomes and Management
JournalSubscription Print/ Electronic
PEDroPhysical Therapy website
WebsiteDatabase
FREE - Filtered http://www.pedro.org.au/
Index to the Chiropractic Literature
Database: Bibliographic
FREE - Unfiltered http://www.chiroindex.org/
Journal of Manipulative andPhysical Therapy (JMPT)
Journal Electronic/Print http://www.journals.elsevierhealth.com/periodicals/ymmt
Journal of Clinical Outcomes and Management
JournalSubscription Print/ Electronic
Centre for Evidence-basedMedicine
Website FREE http://www.cebm.net/index.aspx?o=1011
Additional Resources for Obtaining Evidence
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