Report examples

Below is an example of a report request for an orthopaedic injury.

Details

Claim Number:

Claimant Name:

Diagnosis:

Date of Injury:

Diagnosis and present condition

Under this heading you need to provide:

• diagnosis of all conditions with specification of what is work related
• the injury history
• comment on the event as described by the worker
• comment on whether the mechanism of injury is consistent with worker’s report of the injury.  (answer: yes, no or unsure)
• the patient's present condition at current clinical examination
• relevant past medical history including pre-existing conditions/injuries and if the injury is an aggravation.

Treatment and rehabilitation plan for injury resolution

This section of the report can replace the need for ongoing Workers’ Compensation Medical certificates if this section is comprehensively completed for the entire injury resolution time frames. WorkCover will need a Workers' Compensation Medical Certificate to cover any period up until the receipt of this report.

Things to include:

• Reported treatment received prior to your assessment
• Current medications and dosage
• Treatment and rehabilitation plan, including time frame to determine if surgical procedure will be requested
• Time frame for return to work – if graduated return to work, provide appropriate times for upgrade
• Restricted duties (think capacity not incapacity – It is WorkCover’s job to find them work based on the restrictions.  We might not be able to return them to their pre-injury job but we might be able to find an appropriate host employer.  If we can’t find them work, the injured worker receives the same benefits as if totally incapacitated.)
• What allied health services should be accessed?   Consider: Physiotherapy, Psychology (Adjustment to Injury Counselling), Chiropractic, Occupational Therapist.
• If allied health services should be accessed, provide details of your proposed treatment plan. Consider:  Time frames, number of services and expected outcome.

Operative Findings

If the injury required surgery and it has already been completed, please provide an outline of the surgery performed including:

• a copy of the operation notes
• your operative findings outlining the injury changes seen
• what treatment was provided.

Likely fitness for pre-injury occupation

• Should they consider a different occupation in the future?
• Please advise of functional considerations so we can appropriately match future return to work plans.

Collateral conditions likely to impact on plan

• Relevant psychosocial factors that could impact on treatment, recovery and/or return to work.

Additional comments

• Would you like this worker to be reviewed by an IME?
• Ask for contact to be made by the Customer Advisor to discuss the claim further
• Note anything that does not fit into a category above that you think is relevant to the workers’ compensation claim.

Below are example questions for a work-related psychological/psychiatric injury.

• Diagnosis
  • Is there a DSM diagnosis? (Relevant to initial or early claims).
  • Is there still a DSM diagnosis? (Was there a condition that has now resolved?)
• Relevant past medical history—summary of matters relevant to current diagnosis.
• Is the condition a result of employment?
• Does the psychiatric injury arise as a result of a physical injury?
• Results of investigations or does the diagnosis require further investigation with blood tests or radiological examination? (Please organise any required investigations.)
• Does the injured worker require any further assessment of neuro-psychological status or cognitive function?
• List of stressors—specify all work and non-work related stressors.
• Aspects of treatment and rehabilitation
• Results of treatment and rehabilitation to date
• Comment on the likely outcome of current treatment and rehabilitation in returning the injured worker to work.
• Comment on possible options and time frames for future treatment and rehabilitation.
• Prognosis
  • When do you anticipate the injured worker will be fit to return to work? Include recommended hours and restrictions. Please limit comments on potential incapacity to the next six months—if you feel the incapacity is likely to extend beyond this, please suggest a future review date where you can re-examine the injured worker.
  • Could the injured worker return to any form of work at this time? This might be unrelated to their original employment. If yes, how many hours a week would you recommend and what restrictions or alternate duties might apply and for how long?
  • Is full recovery likely?
  • Is the condition stable and stationary? A condition is stable and stationary when the condition is not likely to improve with further treatment. This suggests that the condition has reached maximal medical improvement and that suitable rehabilitation has been carried out.