What this is
What is a medical treatment report?
What is a medical treatment report?
It is the record a supervisor completes once a worker who was injured at work has been seen by a medical provider and treated with something beyond first aid. It captures what was done, who did it, and whether the worker was given restrictions or time away. It is not a diagnosis form and it is not the incident report itself — it sits downstream of both, triggered by the outcome of the medical visit rather than the event.
What counts as 'beyond first aid' under OSHA?
OSHA 1904.7(b)(5)(ii) lists specific treatments that are deemed first aid regardless of who administers them: a single dose of an over-the-counter medication, cleaning and dressing a wound, hot or cold therapy, non-rigid supports, and a handful of others. Anything past that list — sutures, prescription-strength medication, more than one dose of an OTC drug, or a rigid immobilising device — is medical treatment beyond first aid, and the case is recordable.
How is this different from a first aid report?
The First Aid Report exists for the cases that stay inside OSHA's first aid list — treated on site, worker returns to the task, nothing to report. This template exists for the cases that cross that line. The two forms look similar and are often confused at the point of writing, which is the recurring source of misclassified recordkeeping.
Scope
When is a medical treatment report required?
This record exists for a narrow band of outcome: treatment happened, and it went beyond what OSHA classifies as first aid. Reaching for it too early or too late produces a case file that misrepresents the actual severity of what happened.
Use this template when
- A worker has been seen by a medical provider and treated with something on the medical-treatment side of the OSHA first aid line
- The treatment has already happened and the facts of it — provider, date seen, what was done — are known, not projected
- The case needs a durable ID so it can be linked from RCA, CAPA, and any resulting health case
- Work restrictions or time away are being issued, even if only for part of a shift
- A regulatory notification may follow, and the case needs to exist before that notification is made
Do not use it for
- First Aid Report, which records a minor injury treated on site with no further medical care needed.
- Incident Report, which records any unplanned event that caused harm, damage or loss, and comes first in the chain.
- Lost Time Report, which takes over once the worker is away from work beyond the day it happened.
- Near Miss Report, which records something that could have caused harm but did not.
- Anything outside KnowSafe, which belongs in the workspace that owns that process.
Compliance mapping
Which OSHA 1904.7 requirements does this satisfy?
The form is built around the single determination OSHA cares about most: did the treatment given cross the line out of first aid. Everything else on the page exists to support or act on that determination.
| Clause | Requirement | Where it lands |
|---|---|---|
| OSHA 1904.7(b)(5)(ii) | Lists the specific treatments that remain first aid regardless of severity; anything outside the list is medical treatment. | Medical detail |
| OSHA 1904.7(b)(4) | Defines medical treatment beyond first aid as the trigger for a recordable case. | Medical detail |
| OSHA 1904.7(b)(1) | Establishes that the case must first be work-related before any recordability question applies. | Event |
| OSHA 1904.7(b)(3) | Restricted work or job transfer is recorded separately from the medical treatment determination itself. | Medical detail |
| OSHA 1904.29(b)(3) | Records must be entered within seven calendar days of receiving the information that a recordable case occurred. | Event |
| OSHA 1904.39(a) | Certain outcomes — in-patient hospitalisation, amputation, loss of an eye — carry a separate, faster reporting duty to OSHA. | Immediate response |
| OSHA 1904.5 | Determination of work-relatedness governs whether the case belongs in this record at all. | What happened |
What it does not cover
- A single dose of an over-the-counter drug written up as medical treatment, which overstates the case and can distort the site's recordable rate in the other direction.
- A prescription-strength medication logged without naming the provider, which leaves the recordability call unverifiable later.
- Work restrictions issued verbally but never entered against Restriction Record ID, which breaks the link to the health case tracking the restriction.
- A wound closure method left undescribed in Treatment Beyond First Aid, which is often the one detail that actually decides first aid versus medical treatment.
- Reportable To Regulator marked No without checking the hospitalisation and amputation triggers, which is a distinct duty from ordinary OSHA recordkeeping.
Global
Medical Treatment Report requirements by country
OSHA's first aid list is a US federal construct, and its exact boundary shifts once a case crosses a state line or a national border.
29 CFR 1904.7
The default reading throughout this template — the first aid list, the seven-day entry window, and the severe-injury reporting duty all come from this Part.
If the employer sits under federal OSHA jurisdiction, the classification made here is the one that determines whether the case appears on the OSHA 300 log.
State OSHA-equivalent recordkeeping rules
State plans must be at least as protective as federal OSHA but sometimes narrow the first aid list further or add reporting duties of their own.
A treatment that is first aid under federal rules is not guaranteed to be first aid under a state plan; confirm the local rule before relying on the federal list alone.
Local injury and illness reporting frameworks (e.g. RIDDOR in the UK, provincial WCB rules in Canada)
The first aid versus medical treatment line is a US-specific construct; other jurisdictions classify by different tests — reportable injury categories, days of incapacity, or a defined dangerous occurrence list.
Do not port the OSHA first aid list into a non-US site; use it only as a reference point and confirm the actual local reporting duty.
How to complete it
How to complete a medical treatment report, step by step
Filling in the fields is mechanical once the medical facts are known. The judgement calls sit in how those facts are interpreted.
A single dose of an OTC drug is first aid; a second dose administered later for the same injury is medical treatment. The distinction hinges on counting doses across the whole treatment course, not just what happened at the first visit.
A soft brace or non-rigid wrap stays first aid; a rigid splint or cast crosses the line. Providers do not always describe the device in those terms, so the person completing the form has to translate the clinical note into the OSHA category.
A provider's informal advice to 'take it easy' is not the same as a documented work restriction. Only a restriction the employer is obligated to honour should drive Work Restrictions Issued and the downstream health case.
Actual Severity records what happened; Maximum Potential Loss records what could have happened under slightly different circumstances. A minor medical treatment case with high potential severity still earns a serious investigation, and conflating the two understates the risk on record.
What auditors find
Most common medical treatment report findings
The same handful of gaps show up across sites when this record is audited against the medical file it should match.
| Finding | Clause | What fixes it |
|---|---|---|
| Treatment described only as 'seen by doctor' with no detail of what was actually done. | OSHA 1904.7(b)(4) | Require the specific treatment given in Treatment Beyond First Aid, not the fact of the visit. |
| Restriction Record ID left blank despite Work Restrictions Issued marked Yes. | OSHA 1904.7(b)(3) | Enforce the link before the case can be closed, so the health case tracking the restriction actually exists. |
| Case entered more than seven calendar days after the employer learned of it. | OSHA 1904.29(b)(3) | Alert on Date Reported versus the date the employer was notified, not just the event date. |
| Reportable To Regulator marked No on a case that involved in-patient hospitalisation. | OSHA 1904.39(a) | Cross-check hospitalisation and amputation against the regulator field before allowing No. |
| Guard Or Control In Place left unanswered when Equipment Involved was Yes and the machine was running. | OSHA 1904.5 | Make the guard question mandatory whenever machine involvement and running status are both confirmed. |
| RCA ID never populated despite Investigation Required marked Yes. | Internal investigation policy | Block case closure until a linked RCA reference exists for every case flagged as requiring investigation. |
Case in point
Case in point: the second dose that changed the log
A worker cut a hand on a boning line and was sent to the on-site nurse, who cleaned and dressed the wound — textbook first aid, and the supervisor logged it that way without a second thought. Two days later the worker came back with swelling, and an off-site provider prescribed an antibiotic and a second round of wound care.
Because the case had already been closed as first aid, nobody went back to reclassify it once the prescription was added. The site's recordable rate for that quarter understated the true count by one case, and it only surfaced when an auditor cross-referenced the health case against the original medical treatment record and found the prescription with no matching entry here.
The template
The template, field by field
The form exactly as it installs. Every field, option, score and conditional rule is editable, and the links to other templates come with it.
7 sections
- Reference
- SAF-004
- Archetype
- Record
- Record ID
- CASE-2026-000
- Scoring
- Actual severity
- Direction
- High is bad
- Singleton
- No
- Basis
- OSHA 1904.7
- Links
- Feeds RCA, KnowHealth case
- Tags
- Incident, Lagging
- Sections
- 7
- Fields
- 48
- Follow up fields
- 13
- Repeating sections
- 0
- Links out
- 8
Event
6 fieldsCase ID*
Auto sequence. Format CASE-2026-00000.
The record's own ID. Other templates point at this value.
Status*
Drives who this goes to next.
- Planned2 pts
- In progress2 pts
- Complete3 pts
- Deferred0 pts
- Open0 pts
- Closed3 pts
- Overdue0 pts
Date and Time of Event*
Date Reported*
A gap between these two is worth understanding on its own.
Reported By*
Person ID*
Format PER-0000.
Links to FDN-003 Person ID
Where
4 fieldsSite*
Site ID*
Format SITE-000.
Links to FDN-001 Site ID
Area*
The area within the site.
Exact Location
Drop a pin for anything hard to find.
What happened
7 fieldsDescription*
Facts only. What happened, in the order it happened.
Photographs
Wide shots and close ups, before anything is moved.
Equipment Involved*
Asset
Asset ID
Format AST-0000.
Links to FDN-002 Asset ID
Was Machine Running
Guard Or Control In Place
- Yes, correctly fitted2 pts
- Yes, but bypassed0 pts
- No0 pts
Medical detail
11 fieldsInjured Person*
Person ID*
Format PER-0000.
Links to FDN-003 Person ID
Body Part*
Injury Type*
Provider Name*
Date Seen*
Treatment Beyond First Aid*
Describe the treatment, not the diagnosis.
Work Restrictions Issued*
- No2 pts
- Yes0 pts
Restriction Record ID
Links to HLT-017 Record ID
Health Case ID
Opened where ongoing medical management is needed.
Links to HLT-016 Case ID
Expected Return Date
Severity and potential
6 fieldsSeverity Guidance
Medical treatment is a recordable outcome in most jurisdictions. Confirm your reporting duty before the shift ends.
Actual Severity*
- No injury4 pts
- First aid3 pts
- Medical treatment2 pts
- Lost time1 pt
- Fatality0 pts
Maximum Potential Loss*
The worst credible outcome had circumstances been slightly different.
- Minor4 pts
- Moderate3 pts
- Serious2 pts
- Fatal or catastrophic0 pts
Investigation Required*
Set by potential outcome, not by what actually happened.
- No3 pts
- Yes0 pts
Investigation Level
RCA ID
Format RCA-2026-00000.
Links to FDN-013 RCA ID
Immediate response
8 fieldsImmediate Action Taken*
What was done to make the area safe before anyone left.
Area Made Safe*
Scene Preserved
Work Stopped
Reportable To Regulator*
- No3 pts
- Yes0 pts
Regulator
Notification Reference
Links to SAF-010 Notification ID
Notification Made
Follow up
6 fieldsAction Required*
Raise the action record, then enter its reference here.
- No2 pts
- Yes0 pts
Priority
- High0 pts
- Medium1 pt
- Low3 pts
CAPA ID
Format CAPA-2026-00000.
Links to FDN-014 CAPA ID
Action Owner
Supervisor*
Signature*
SAF-004 · record IDs look like CASE-2026-000 · Feeds RCA, KnowHealth case
Open in KnowellaRun it with agents
From a document you fill in to a programme that runs itself
The determination on this form is the easy part to get right once; keeping every linked case, restriction and regulatory clock in view over weeks is the part that actually slips.
Holds the medical treatment case against the incident it came from, flags cases missing a required RCA or restriction link, and keeps the OSHA recordability trail defensible.
Owns the health case once restrictions or ongoing medical management are opened, tracking the return-to-work path against the expected return date entered here.
Watches the regulatory notification clock once Reportable To Regulator is set, and keeps the notification reference tied back to this case.
Coordinates the crew across KnowSafe and KnowHealth, rolls open restrictions and overdue investigations into one view, and holds every write for your approval before it touches a record.
This template lives in KnowSafe — safety and compliance. Incidents, hazards, permits, inspections and the critical controls behind them.
Meet KnowSafe→Glossary
Medical Treatment Report definitions and key terms
- OSHA
- The US Occupational Safety and Health Administration, the federal regulator whose recordkeeping rules govern this template's core determination.
- Recordable injury
- An injury that meets one of OSHA's specific criteria — including medical treatment beyond first aid — and must appear on the OSHA 300 log.
- First aid (OSHA definition)
- A closed, specific list of treatments in 1904.7(b)(5)(ii) that remain non-recordable no matter how the treatment is delivered.
- Restricted work case
- A case where the worker is medically restricted from performing their normal job duties, tracked separately from lost time.
- Case thread
- The set of linked records — incident, medical treatment, RCA, CAPA, health case — that together tell the full story of one event.
FAQ
Frequently asked questions about medical treatment report
Who completes the medical treatment report?+
The supervisor, once the worker has been seen by a medical provider and the treatment given is known. It is not completed at the scene of the injury; that belongs to the incident or first aid record instead.
What happens if the treatment turns out to be first aid after all?+
The case can be reclassified, but the record should stay auditable — note why the determination changed rather than deleting and re-raising under a different template.
Does this record trigger an OSHA report on its own?+
Not by itself. Ordinary medical treatment cases are recorded on the OSHA 300 log, not reported to OSHA directly. Only specific severe outcomes — hospitalisation, amputation, loss of an eye, fatality — carry the separate, faster reporting duty.
Why does this form ask about equipment and guarding?+
Because the same case usually needs an investigation, and the guarding question determines how quickly and how seriously that investigation needs to run.
How does this link to a health case in KnowHealth?+
When restrictions are issued or the injury needs ongoing medical management, Health Case ID opens a linked record there, so the return-to-work and restriction tracking does not live only inside this one form.
Can the OSHA first aid list be edited in the template?+
The options and scoring can be edited like any other field, but the underlying regulatory list should not be altered casually — it is a legal definition, not a house preference.
Keep going
Related templates and programmes
Industries this is written for
Programmes this belongs to
Used together in Incident and Investigation
Root Cause Analysis
Finds out why something happened rather than who was involved
Corrective and Preventive Action
The single action record used everywhere
Finding
Records a single deficiency picked up during an audit, inspection or check
Effectiveness Verification
Checks whether an action actually worked, some time after it was put in place
Just Culture Determination
Separates a system problem from a genuine choice to take a risk, using a consistent set of questions
Extent of Condition Review
Asks two questions after an investigation: where else does this same condition exist, and where else could this same cause bite us
More in Incidents
Incident Report
Records any unplanned event that caused harm, damage or loss
Near Miss Report
Records something that could have caused harm but did not
First Aid Report
Records a minor injury treated on site with no further medical care needed
Lost Time Report
Records an injury that keeps a worker away from work beyond the day it happened
Property Damage Report
Records damage to equipment, buildings or stock where nobody was hurt
Vehicle Incident Report
Records a collision or vehicle event on site involving forklifts, yard trucks or visiting vehicles
Written and reviewed by
Siddarth Singh
Founder & Chief Executive Officer, Knowella
Certified Safety Professional and industrial and systems engineer with more than a decade inside food supply chain, freight and manufacturing operations. This page was written against the current text of the standards it cites, not against secondary summaries of them.
- Certified Safety Professional (CSP), Board of Certified Safety Professionals
- MBA, University of Chicago Booth School of Business
- MS and BS, The Ohio State University, Industrial and Systems Engineering
- Six Sigma Black Belt
Sources and last review. Reviewed 16 August 2026 against:
- OSHA 29 CFR 1904.7 — General recording criteria
- OSHA 29 CFR 1904.7(b)(5)(ii) — First aid treatments excluded from recording
- OSHA 29 CFR 1904.29 — Forms and completion timing
- OSHA 29 CFR 1904.39 — Reporting fatalities, hospitalisations, amputations and loss of an eye
This page is general guidance, not legal advice. Confirm requirements with your jurisdiction’s regulator.