Activity Prescription Form - Washington State Department Of Labor Page 2
Download a blank fillable Activity Prescription Form - Washington State Department Of Labor in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Activity Prescription Form - Washington State Department Of Labor with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Discuss your patient’s role in their recovery
Research has shown that returning to activity (including lighter work) speeds recovery and reduces the risk of
becoming disabled from most work-injuries. In addition to providing good clinical care, it is important to set
expectations for a good recovery and assure patients understand the importance of doing their part. Take just a
couple minutes during an initial office visit to explain the following (check each one as you complete it):
Key Messages
1. “You must help in your own recovery…”
Only you can ensure your own successful recovery.
It’s your job (and my expectation) that you follow activity recommendations (both at home and at work).
2. “Activity helps recovery…”
Bodies heal best with activity that you can safely do, and need to do, to recover.
Incrementally increase the activity you do a little bit, each day.
Some discomfort is normal when returning to activities after an injury. This is not harmful, and is different
from pain that indicates a setback.
3. “Early and safe return to work makes sense…”
Return to work is one of the goals of treatment.
The longer you are off work, the harder it is to get back to your original job and wages.
Even a short time off work takes money out of your pocket because time loss payments do not pay your
full wage.
To be paid for this form, providers must:
Important notes
A provider may submit up to 6 APFs per worker within
1. Submit this form:
With reports of accident when there
the first 60 days of the initial visit date and then up to
are work related physical restrictions, or
4 times per 60 days thereafter.
When documenting a change in your
Use this form to communicate expectations of the
patient’s medical status or capacities.
patient to be physically active during recovery, work
2. Complete all relevant sections of the form.
status, activity restrictions, and treatment plans.
This form will also certify time-loss compensation, if
3. Send chart notes and reports as required.
appropriate.
Occupational and physical therapists, office staff, and
others will not be paid for working on this form.
To learn how to complete this form, go to
About impairment ratings
We encourage you, the qualified attending health-care provider, to rate your patient’s permanent impairment. If
this claim is ready to close, please examine the worker and send a rating report.
Qualified attending health-care providers include doctors currently licensed in medicine and surgery (including
osteopathic and podiatric) or dentistry, and chiropractors who are department-approved examiners.
Thank you for treating this injured worker.
F242-385-000 Activity Prescription Form (APF) 11-2014
Index: APF
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Doh 420-098 - Carbapenem-resistant Enterobacteriaceae Form - Washington State Department Of Health
Legal
Form Doh 422-066 - Psychiatric/psychological Consultant's Compliance Form - Washington State Department Of Health
Legal
Buyers' Certificate Of Tax Exempt Export Carbonated Beverage Syrup Form - Washington State Department Of Revenue
Financial
Related Categories
Parent category: Medical