Form Msi 379 - Bcbs Physician Statement - Cardiac Page 2
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2PART V: MANAGEMENT PLAN FOR THE CURRENT CONDITION
DATE (YYYY | MM | DD)
I
I
DATE (YYYY
MM
DD)
Frequency of visits ____________________________________________________
I
I_
Date of most recent visit ________________________________________________
I
I_
Date of re-evaluation __________________________________________________
I
I_
Hospitalization dates - include admission/discharge summaries
______________________________________________________________________
I
I_
______________________________________________________________________
I
I_
_______________________________________________________________________
I
I_
_______________________________________________________________________
I
I_
Surgery date(s) and type(s) - include operative report(s)
_______________________________________________________________________
I
I_
_______________________________________________________________________
I
I_
_______________________________________________________________________
I
I_
Medication – include dosage
______________________________________________________________________
I
I_
______________________________________________________________________
I
I_
______________________________________________________________________
I
I_
______________________________________________________________________
I
I_
Name of Other Health Care Providers
Specialty
Other specialists _______________________ _____________________________
I
I_
Counsellor ___________________________ _____________________________
I
I_
Therapist _____________________________ _____________________________
I
I_
Is the patient following recommended treatment program?
Yes
No If no, explain circumstances ___________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
PART VI: ESTIMATED TIME FOR RECOVERY
1.
Current Status
Stable
Improving
Regressing
2.
Restrictions and Limitations
Functional capacity per Canadian Cardiovascular Society (CCS)
Level 1
Level 2
Level 3
Level 4
(no limitations)
(mild impairment)
(moderate impairment)
(severe impairment)
Weight
Frequency
Duration
What specific restrictions or limitations prevent
the patient from performing the duties of his/her
Lifting/
1-10 lb (0.5-4.5 kg)
occupation?
Carrying
11-20 lb (5-9.1 kg)
21-50 lb (9.5-22.7 kg)
How does this affect the patient’s ability to
perform activities of daily living?
Pushing/
1-10 lb (0.5-4.5 kg)
Pulling
11-20 lb (5-9.1 kg)
21-50 lb (9.5-22.7 kg)
Standing
Walking
Other
3.
In your opinion, is the patient a suitable candidate for a work re-entry program (i.e., ease-back, modified duties, gradual return
to work, etc.)?
Yes
No
Provide comments and recommendations. _______________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
4.
Any additional information or details that may have a significant impact on the patient’s recovery from this condition?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Signature _______________________________________________________ Date __________________________________
® Saskatchewan Blue Cross is a registered trade-mark of the Canadian Association of Blue Cross Plans, used under license by Medical Services Incorporated, an independent licensee.
MSI 379 09/13
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