These reports should include where applicable:
(a) the date of the examination;
(b) the history of the injury;
(c) the patient's complaints;
(d) a listing of all information received from the parties reviewed in preparation of the report or relied upon for the formulation of the physician's opinion;
(e) the patient's medical history, including injuries and conditions, and residuals thereof, if any;
(f) findings on examination;
(g) a diagnosis;
(h) opinion as to the nature, extent, and duration of disability and work limitations, if any;
(i) cause of the disability;
(j) treatment indicated;
(k) opinion as to whether or not permanent disability has resulted from the injury and whether or not it is stationary. If stationary, a description of the disability with a complete evaluation;
(l) apportionment of disability, if any;
(m) a determination of the percent of the total causation resulting from actual events of employment, if the injury is alleged to be a psychiatric injury;
(n) the reasons for the opinion; and,
(o) the signature of the physician.
Failure to comply with (a) through (o) will be considered in weighing the evidence.
In death cases, the reports of non-examining physicians may be admitted into evidence in lieu of oral testimony.
All medical-legal reports shall comply with the provisions of Labor Code Section 4628. Except as otherwise provided by the Labor Code, including Labor Code Sections 4628 and 5703, and the rules of practice and procedure of the Appeals Board, failure to comply with the requirements of this section will not make the report inadmissible but will be considered in weighing the evidence.
Authority cited: Sections 133 and 5307, Labor Code. Reference: Sections 4603.2, 4628, 5703, 5708 and 5709, Labor Code.
1. New subsections (i), (j) and (k) filed 5-25-82; designated effective 7-1-82 (Register 82, No. 22).
2. Editorial correction of subsection (h) filed 2-2-83 (Register 83, No. 6).
3. Amendment filed 12-23-93; operative 1-1-94. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 93, No. 52).
4. Amendment of section and Note filed 12-19-2002; operative 1-1-2003. Submitted
to OAL for printing only pursuant to Government Code section 11351 (Register
2002, No. 51).
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