New York State Medical Treatment Guidelines for History Taking
and Physical Examination in workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for History Taking and Physical Examination.

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders. The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

History Taking and Physical Examination of Shoulder Injury

When initially assessing shoulder instability due to labour, two standard approaches should be used.All subsequent stages of diagnostic and therapeutic treatments are dictated by and built upon these processes.When findings from clinical evaluations and those from other diagnostic techniques do not agree, preference should be given to the objective clinical findings.The following should be appropriately documented in the medical records:

History Taking
For each shoulder injury diagnosis, the history should cover at least these topics:

  • comprehensive medical history.
  • Occupational connection.
  • It is necessary to specifically detail any history of non-occupational injuries and extracurricular activities.
  • prior condition of the neck, shoulders, and/or arms (s).
  • It is important to conduct a system review, which may include signs or symptoms from the following organ systems: integumentary/breast; neurological; psychiatric; hematologic/lymphatic; allergic/immunologic; constitutional symptoms; eyes; ear, nose, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; The scope and focus of the assessment of systems can vary from case to case depending on the underlying ailment being treated and clinical judgement.

What our office can do if you have workers compensation injuries

We have the experience to help you with their workers compensation injuries. We understand what you are going through and will meet your medical needs and follow the guidelines set by the New York State Workers Compensation Board.

We understand the importance of your workers compensation cases. Let us help you navigate through the maze of dealing with the workers compensation insurance company and your employer.

We understand that this is a stressful time for you and your family. If you would like to schedule an appointment, please contact us so we will do everything we can to make it as easy on you as possible.


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