California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5 - Predesignation of Personal Physician; Request for Change of Physician; Reporting Duties of the Primary Treating Physician; Petition for Change of Primary Treating Physician › Section 9785.3 - Form PR-3 "Primary Treating Physician's Permanent and Stationary Report."

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
STATE OF CALIFORNIA
Division of Workers' Compensation
PRIMARY TREATING PHYSICIAN'S PERMANENT AND
						STATIONARY REPORT (PR-3)
_____________________________________________________________________________________________________________
This form is required to be used for ratings prepared
						pursuant to the 1997 Permanent Disability Rating Schedule. It is designed to be
						used by the primary treating physician to report the initial evaluation of
						permanent disability to the claims administrator. It should be completed if the
						patient has residual effects from the injury or may require future medical
						care. In such cases, it should be completed once the patient's condition
						becomes permanent and stationary.
This form should not be used by a Qualified Medical
						Evaluator (QME) or Agreed Medical Evaluator (AME) to report a medical-legal
						evaluation.
___________________________
Patient:
Last Name ____________________ Middle Initial ___ First
						Name ____________________ Sex ___ Date of Birth ____________________
Address ____________________________________ City
						________________________ State ____ Zip __________________________
Occupation ___________________________ Social Security
						No. _______________________________ Phone No. _________________
Claims
						Administrator/Insurer:
Name _______________________________________ Claim No.
						_____________________________ Phone No. __________________
Address _____________________________________ City
						__________________________ State _____ Zip ______________________
Employer:
Name
						___________________________________________________________________________
						Phone No. ____________________
Address _____________________________________ City
						__________________________ State _____ Zip ______________________
_____________________________________________________________________________________________________________
You must address each of the issues below. You may
						substitute or append a narrative report if you require additional space to
						adequately report on these issues.
_____________________________________________________________________________________________________________
Date of Injury ____________________(Date) Last date
						worked ____________________(Date) Date of current examination
						____________________(Date)
Permanent & Stationary date
						____________________(Date)
Description of how injury/illness
						occurred
(e.g. Hand caught in punch press; fell from height onto
						back; exposed 25 years ago to asbestos):
Patient's
						Complaints:
STATE OF CALIFORNIA
Division of Workers' Compensation
PRIMARY TREATING PHYSICIAN'S PERMANENT AND
						STATIONARY REPORT (PR-3)
Relevant Medical
						History:
Objective
						Findings:
Physical Examination:
(Describe all relevant
						findings; include any specific measurements indicating atrophy, range of
						motion, strength, etc.; include bilateral measurements - injured/uninjured -
						for upper and lower extremity injuries.)
Diagnostic tests results
(X-ray/Imaging/Laboratory/etc.)
Diagnoses
(List each
								diagnosis; ICD-9 code must be included)
ICD-9
1.
								___________________________
___________________________
2. ___________________________
___________________________
3. ___________________________
___________________________
4. ___________________________
___________________________
___________________________
Yes
No
Cannot
								determine
Can this patient now return to his/her usual
								occupation?
[]
[]
[]
If not, can the patient perform another line of
								work?
[]
[]
[]
STATE OF CALIFORNIA
Division of Workers' Compensation
PRIMARY TREATING PHYSICIAN'S PERMANENT AND
						STATIONARY REPORT (PR-3)
_____________________________________________________________________________________________________________
Subjective
						Findings
:
Provide your professional assessment of the
						subjective factors of disability, based on your evaluation of the patient's
						complaints, your examination, and other findings. List specific symptoms (e.g.
						pain right wrist) and their frequency, severity, and/or precipitating activity
						using the following definitions:
Severity
:
Minimal
								pain - an annoyance, causes no handicap in performance.
Slight pain - tolerable, causes
								some handicap in performance of the activity precipitating pain.
Moderate pain - tolerable,
								causes marked handicap in the performance of the activity precipitating
								pain.
Severe pain - precludes
								performance of the activity precipitating pain.
Frequency
:
Occasional - occurs roughly one fourth
								of the time.
Intermittent - occurs roughly
								one half of the time.
Frequent - occurs roughly three
								fourths of the time.
Constant - occurs roughly 90 to
								100% of the time.
Precipitating
								activity
: Description of precipitating activity gives a sense of how
								often a pain is felt and thus may be used with or without a frequency modifier.
								If pain is constant during precipitating activity, then no frequency modifier
								should be used. For example, a finding of "moderate pain on heavy lifting"
								connotes that moderate pain is felt whenever heavy lifting occurs. In contrast,
								"intermittent moderate pain on heavy lifting" implies that moderate pain is
								only felt half the time when engaged in heavy lifting.
Yes
No
Cannot
								determine
Pre-Injury
								Capacity
Are there any activities at home or at
								work that the patient
[]
[]
[]
cannot do as well now as could be done
								prior to this injury or illness?
If yes, please describe pre-injury capacity and current
						capacity (e.g. used to regularly lift a 30 lb. child, now can only lift 10
						lbs.; could sit for 2 hours, now can only sit for 15 mins.)
1.
2.
3.
4.
_____________________________________________________________________________________________________________
STATE OF CALIFORNIA
Division of Workers' Compensation
PRIMARY TREATING PHYSICIAN'S PERMANENT AND
						STATIONARY REPORT (PR-3)
Preclusions/Work
						Restrictions
Yes
No
Cannot
								determine
Are there any activities the patient cannot
								do?
[]
[]
[]
If yes, please describe all preclusions or restrictions
						related to work activities (e.g. no lifting more than 10 lbs. above shoulders;
						must use splint; keyboard only 45 mins. per hour; must have sit/stand
						workstation; no repeated bending). Include restrictions which may not be
						relevant to current job but may affect future efforts to find work on the open
						labor market (e.g. include lifting restriction even if current job requires no
						lifting; include limits on repetitive hand movements even if current job
						requires none).
1.
2.
3.
4.
5.
6.
Medical Treatment
:
Describe any continuing medical treatment related to this injury that you
						believe must be provided to the patient. ("Continuing medical treatment" is
						defined as occurring or presently planned treatment.) Also, describe any
						medical treatment the patient may require in the future. ("Future medical
						treatment" is defined as treatment which is anticipated at some time in the
						future to cure or relieve the employee from the effects of the injury.) Include
						medications, surgery, physical medicine services, durable equipment,
						etc.
Comments:
STATE OF CALIFORNIA
Division of Workers' Compensation
PRIMARY TREATING PHYSICIAN'S PERMANENT AND
						STATIONARY REPORT (PR-3)
Apportionment:
Effective April 19, 2004, apportionment of permanent
						disability shall be based on causation. Furthermore, any physician who prepares
						a report addressing permanent disability due to a claimed industrial injury is
						required to address the issue of causation of the permanent disability, and in
						order for a permanent disability report to be complete, the report must include
						an apportionment determination. This determination shall be made pursuant to
						Labor Code Sections
						4663 and
						4664, set forth
						below:
Labor Code section
						4663.
						Apportionment of permanent disability; Causation as basis; Physician's report;
						Apportionment determination; Disclosure by employee
(a) Apportionment of permanent disability
					 shall be based on causation.
(b)
					 Any physician who prepares a report addressing the issue of permanent
					 disability due to a claimed industrial injury shall in that report address the
					 issue of causation of the permanent disability.
(c) In order for a physician's report to be
					 considered complete on the issue of permanent disability, it must include an
					 apportionment determination. A physician shall make an apportionment
					 determination by finding what approximate percentage of the permanent
					 disability was caused by the direct result of injury arising out of and
					 occurring in the course of employment and what approximate percentage of the
					 permanent disability was caused by other factors both before and subsequent to
					 the industrial injury, including prior industrial injuries. If the physician is
					 unable to include an apportionment determination in his or her report, the
					 physician shall state the specific reasons why the physician could not make a
					 determination of the effect of that prior condition on the permanent disability
					 arising from the injury. The physician shall then consult with other physicians
					 or refer the employee to another physician from whom the employee is authorized
					 to seek treatment or evaluation in accordance with this division in order to
					 make the final determination.
(d)
					 An employee who claims an industrial injury shall, upon request, disclose all
					 previous permanent disabilities or physical impairments.
Labor Code section
						4664. Liability
						of employer for percentage of permanent disability directly caused by injury;
						Conclusive presumption from prior award of permanent disability; Accumulation
						of permanent disability awards
(a) The employer shall only be liable for the
					 percentage of permanent disability directly caused by the injury arising out of
					 and occurring in the course of employment.
(b) If the applicant has received a prior
					 award of permanent disability, it shall be conclusively presumed that the prior
					 permanent disability exists at the time of any subsequent industrial injury.
					 This presumption is a presumption affecting the burden of proof.
(c)
(1) The
					 accumulation of all permanent disability awards issued with respect to any one
					 region of the body in favor of one individual employee shall not exceed 100
					 percent over the employee's lifetime unless the employee's injury or illness is
					 conclusively presumed to be total in character pursuant to Section
					 4662. As used in this section, the
					 regions of the body are the following:
(A)
					 Hearing.
(B) Vision.
(C) Mental and behavioral
					 disorders.
(D) The spine.
(E) The upper extremities, including the
					 shoulders.
(F) The lower
					 extremities, including the hip joints.
(G) The head, face, cardiovascular system,
					 respiratory system, and all other systems or regions of the body not listed in
					 subparagraphs (A) to (F), inclusive.