Form 8/10 - Physician'S Report - Workplacenl - 2015
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7Instructions for Completing
SEND BY FAX ONLY
CONTACT US AT:
VISIT US AT:
Physician's Report 8/10
workplacenl.ca
t
709.778.1000
f 709.738.1479
t
1.800.563.9000
f 1.866.553.5119
A physician would complete this report for:
1.
New injuries – The physician or worker believes the injury is work-related.
2.
Recurrences – The injury may be a recurrence of a previous work-related injury.
3.
Progress reporting – When there is a significant change in the worker’s: (1) condition; (2) treatment; or (3) return-to-
work status.
On the day of the visit:
Provide the employer's copy of the form 8/10 to the injured worker, who will then give it to the employer. Only sections
outlined in red are visible on the employer's copy.
Complete and legible reporting:
Reporting fees will not be paid for incomplete or illegible reports.
physician's
Please do not use a stamp for any information including
name, contact information or billing number. Stamps are
not permitted as this is a triplicate form. Information provided by stamp will not be visible on the worker and employer copies
of the form. Forms using stamps will be considered illegible.
Section B - Specific Information for Parts of Body Injured:
It is not necessary to provide the Mechanism of Injury information on reports subsequent to the initial report unless there
is a change in the information provided or additional information is available.
Coding is used in this section as outlined on the reverse of this sheet. Only one code box should be used for each code
entered, regardless if the code has one or two digits (see example below).
First, enter codes for Part(s) of Body and whether the injury pertains to the Left, Right or Center of the specified body
part(s), if applicable. If the code for the Part of Body is not on the code sheet, enter the code for Other and identify the
specific body part in the space below the code.
For each Part of Body, enter coding, as applicable, for Subjective Reports, Objective Findings, Diagnoses, Treatments,
Investigations*, and Assistive Devices*. When outlining the Examination and Treatment Plan, including all applicable
codes is important.
If the Subjective Report, Objective Finding, Diagnosis, Treatment, Investigation and/or Assistive Device is not included
on the code sheet, enter the code for Other. When using Other codes, also enter the Other code number and provide
details for that code in the Additional Comments box (box 8).
The Update Status boxes are used when completing progress reports. They are intended to provide updates on Subjective
Reports and Objective Findings from the previous visit. The Update Status is not required for initial reports of injury.
*Note:
The Investigations category is only intended for referrals being made at the time of this visit. Recommendations for assistive
devices may also require completion of a Health Care Devices and Supplies Prescription form.
Section B Example
SECTION B - SPECIFIC INFORMATION FOR PARTS OF BODY INJURED
6
Mechanism of injury / incident:
Same as previously reported on the initial report.
U
se codes from
code
sheet
7
Did this injury
Examination
Treatment plan
use more than one code where necessary
aggravate a
prior health issue?
Part of Body
Objective Findings
Diagnoses
Treatments
Investigations Assist. Devices
Subjective Reports
Code
1
2
3
4
1
2
3
4
1
2
3
1
2
1
2
1
2
Yes
No
22
1
10
92
27
20
i.
Right
11
Left
Centre
Don’t know
Other:
C
Update Status
C
C
Are there other
ii.
90
Right
29
1
Left
Centre
issues affecting
the worker’s injury,
Other:
Nose
A
Update Status
recovery and / or
disability?
iii.
Right
Left
Centre
Yes
No
Other:
Update Status
Don’t know
If yes to either of the above
8
Additional Comments - or - If you use any of the “other” codes above (except Part of Body), indicate the code # and provide details.
please specify in Box 8.
9 2 - n e ga t i ve b owst ri n g te st
o
o
D e c re a s e d RO M - F. F. 4 0 , E xt. 10 L + R Rot a t i o n N L + R F l ex i o n N
Points to note:
The second Part of Body in this example was not included on the code sheet. Therefore, code 90 is entered for Other
and Nose is written in the text box immediately below the Part of Body code.
Under Objective Findings for the first Part of Body, code 10 is used for decreased range of motion. The details related to
the decreased ROM are documented in the Additional Comments box.
Also under Objective Findings for the first Part of Body, code 92 is entered for Other and 92 - negative bowstring test is
written in the Additional Comments box to specify the details of the Other code.
No Update Status is provided for the negative bowstring test as this finding had not been previously reported.
Section C Specific Information for All Diagnoses
(pertaining to Section B):
Subsection 12 only applies to medications prescribed for the work injury and not medications related to non-work
related injuries or illnesses.
This information is collected under the authority of the Workplace Health, Safety and Compensation Act to determine
PHYSICIAN'S FORM 8/10
Toll free fax
entitlement to benefits and manage the injured worker’s claim. If you have any questions about this, please
MUST BE FAXED ONLY
1.866.553.5119
contact WorkplaceNL's Access to Information and Protection of Privacy (ATIPP) Coordinator at 1.800.563.9000.
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