Narrative_Summary.docx

NARRATIVE SUMMARY Template DIRECTIONS: Write the Narrative Summary in paragraph format as you would a descriptive H & P, placing the information that is listed in the italicized outline in complete sentences within paragraphs under each heading. Italics and outline format found below are for your guidance in using this template only. Please delete any italicized directions and italicized alpha-numerics from the outline after you fill in the Narrative summary information using sentence format, and before saving this NARSUM as an “add note”. ***A SAMPLE MEDICAL NARSUM IS FOUND AT THE END OF THIS TEMPLATE GUIDE*** ***Before beginning, review the table listing required consults/exams/studies (attached-last page)

(1) Demographics: In order, list:

(a) full Name, Rank, and SS#

(b) # years in service (if part of the years in service are reserve/guard, delineate how many for ARC/Active)

(c) Duty AFSC

(d) Current duty title and brief (sentence or two) synopsis of primary duties

(e) If any of the following apply, simply state “Member is currently___________” for: Reserves, Air National Guard, TDRL, Basic Military Trainee, Air Force Academy Cadet, USAF Officer attending initial AFSC training, or USAF Enlisted attending initial technical training.

(f) List whether or not member has approved retirement or separation date and give the date.

(g) Are there any administrative actions pending and, if so, what are they?

(2) History:

(a) Pertinent Past Medical History: In “list” format: condition, year of onset, and state whether “resolved” or “active”. Only list major diagnos(es) which would be a factor in determining a member’s overall health for a “fitness for duty” decision. (Most “resolved” conditions aren’t applicable).

(b) Pertinent Past Surgical History: In “list” format, give name and year of procedure.

(c) Pertinent Family History: List ONLY genetic, heritable disorders related to any condition for which the patient carries a related diagnos(es).

(3) Current Medications: List both medications taken, and medications that have been prescribed and/or recommended that patient is not taking due to “noncompliance” or optional nature. Include dose/freq.

(4) HPI - Potentially Unfitting Diagnos(es): For each potentially unfitting diagnosis as per AFI 48-123, Chapter 5 (or any other diagnosis which affects the member’s ability to perform duties, deploy and/or places a significant burden on the government to either protect or maintain the member), include the following:

(a ) Diagnosis

(b) Month/year of initial onset

(c) What was member doing when injury or symptoms of illness occurred for the first time?

(d) Where was the member (geographical location name) when injury or symptoms of illness first occurred?

(e) Was this condition ever treated during a deployment and did it require an early return from deployment?

(f) Month/year of any hospitalization, ER, or acute care visit, in the last 24 months, related to this condition.

(g) Current medications and/or other treatment modalities used to treat this or related conditions

(h) Prior medications and/or treatment modalities tried, for this condition, and reason for discontinuation.

(i) If narcotics used, give dose, frequency, level of pain control, and history of narcotic use.

(j) Include pertinent positive and negative ROS for this condition/related conditions.

(k) If any condition existed prior to service, please list and tell if/how service has aggravated the condition

(5) Targeted Physical Exam: Note the table (attached) for specific exam elements.

(a) Vital signs to include measured height and weight, with calculated BMI.

(b) Exam should not be lengthy—give a relevant exam that documents the pertinent positive and negative exam findings related to each potentially unfitting condition.

(c) If the member falls under a category in section (1)e above (for example, a Basic Military Trainee), make sure that orthopedic exams include range of motion studies (in degrees), strength, and function. For active duty, these studies will be conducted by the VA if DPAMM directs a full MEB.

(6) Ancillary Study Summary: Note the table (attached) for ancillary requirements.

(a) Pertinent Labs: List pertinent positive and negative labs ONLY. Do not cut/paste groups of labs unless you delete those that are not directly applicable. Provide values over a continuum of time if they pattern a picture of decline or improvement, or unpredictable nature of condition.

(b) Pertinent Rads: Do not copy and paste the entire study. Give the name of study, the date, and a clear picture of the results (impression).

(c) Pertinent Other: refer to attached table for “other” requirements

(7) Consult Summary: Note the attached table. Provide a short, succinct summary of (a) pertinent findings, (b) diagnosis (c) prognosis and (d) recommended frequency of specialty follow-up for each consult. Since the consults will be attached to this NARSUM, only provide (a)-(d) for each consult in this NARSUM.

(8) Current Profile Restrictions: Review AF 469 (must be reviewed as current during NARSUM completion) and list any specific duty restriction, list the diagnos(es) to which the restriction is linked, and the release date of each restriction. Make sure and comment whether the release date currently stated on the AF 469 truly reflects the date the condition is expected to resolve, or if it is just an administrative release date for a scheduled review. We must know when you anticipate that the restriction will be removed, or if it is expected to be a long term and/or permanent restriction. Note: The AF 469 review of restrictions should not be older than 30 days. Please reflect your review in the “Restriction section” of the AF 469 and/or in the NARSUM via the following statement: “Provider reviewed restrictions and they are deemed accurate and appropriate on (date).” Signature required after the statement.

(9) Line of Duty Determination (LOD): Reference AFI 36-2910 for (a) whether or not this is an Administrative LOD determination or (b) if this requires an AF Form 348 LOD determination. If AF Form 348 is required, ensure it is included with Initial RILO package.

(10) Occupational Impact: For each potentially unfitting condition, succinctly summarize: (a) whether or not condition limits the ability to perform duties and/or deploy, (b) the extent of the limitation(s) and (c) Admin LOD determination required or for injury, AF Form 348 needs to be included with IRILO?

(11) Prognosis: For each potentially unfitting condition, state the prognosis for:

(a) full or partial (if partial, state to what degree) recovery, or stabilized maintenance of chronic condition

(b) timeline for recovery or stabilized maintenance of chronic condition

(c) future treatments (surgeries, procedures, studies, etc.) and duration of expected requirements.

(d) list the anticipated annual frequency for each specialty requirement, and expected duration required.

**Remember to delete the italicized guidance prior to saving as an “add note” in AHLTA. Also, delete the attached table.

****All ARC cases require an AF Form 348, Line of Duty (LOD) determination. For Active Duty members AFI 36-2910, Chapter 1, Paragraph 1.5 states when an LOD is required.

Burns

% BSA, ROM, Photographs of affected areas

(12) Addendum (To be written after C&P exam reviewed by provider—make comment as to whether other claimed conditions are UNFITTING or NOT UNFITTING for military service):

SAMPLE: “I have reviewed the C&P exam dated XX XXX XX performed by the Veteran’s Administration Medical Examiner(s). The member has the following additional claimed conditions: Hysterectomy, Bilateral carpal tunnel, GERD, Chostochondritis, Hypothyroidism, Cervicalgia, Left knee condition, Left elbow tendonitis, and Migraine headaches with aura.

None of these conditions are unfitting IAW AFI 41-210 and AFI 48-123, as they do not interfere with the member’s ability to perform the duties of his/her office, grade, rank or rating. The original narrative remains current and accurate when compared to the member’s VA exam. ( ) No updates are required. ( ) The following updates/clarifications are being made:…….”