Personal Injury Cases Doctor Note

Personal Injury Cases Doctor Note


Patient Information

Name: Michael Smith
Date of Birth: January 15, 2050
Address: 456 Maple Ave., Sunnyvale, CA 94086
Phone Number: (555) 987-6543


To Whom It May Concern,

This letter is to confirm that I, Dr. [Your Name], examined Michael Smith on October 1, 2055. The patient was referred to my office due to injuries sustained in a motor vehicle accident on September 28, 2090.

Findings:

Upon examination, the following injuries were noted:

  • Whiplash: Causing neck pain and stiffness.

  • Contusion on Right Knee: Resulting in bruising and swelling.

  • Back Strain: Mild discomfort and limited range of motion.

Treatment Plan:

The patient has been advised to follow the treatment plan outlined below:

  1. Physical Therapy: Twice a week for 6 weeks to address neck and back pain.

  2. Pain Management: Over-the-counter pain relievers, such as ibuprofen, as needed.

  3. Ice Therapy: Apply ice to the knee for 15-20 minutes every 2-3 hours to reduce swelling.

Prognosis:

The prognosis for recovery is favorable with appropriate treatment. However, the patient may require follow-up appointments to monitor recovery and adjust the treatment plan as necessary.

Work/Activity Restrictions:

As a result of the injuries sustained, I recommend the following activity restrictions:

  • No heavy lifting over 20 pounds.

  • Limit standing or walking for extended periods (more than 30 minutes).

Next Appointment:

The patient is scheduled for a follow-up appointment on October 15, 2090.

If you require any additional information, please feel free to contact my office.

Sincerely,


Dr. [Your Name], MD
Board Certified in Orthopedic Surgery

Note Templates @ Template.net