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Department of Labor and Industries
PHYSICAL THERAPY / OCCUPATIONAL THERAPY
Claims Section
PROGRESS REPORT TO CLAIM MANAGERS
PO Box 44291
Olympia WA 98504-4291
Worker’s Name ___________________________________
Claim #_______________________________
Diagnosis ________________________________________
Report for dates of service _________ to _________
Total number of visits (to date for this condition): _______
Cancellations ____ No-Shows ____
Referring Physician __________________________________ Date of latest referral on file ___________
1. List the objective findings based on standard tests and measurements as well as functional deficits identified during: 1) the initial
evaluation, 2) the last progress report, 3) the current status evaluation. Measurable goals should include a timeframe. Examples of
baseline data include ROM, strength, endurance, functional (work-related) tasks or activities, soft tissue status, etc.
Baseline Measures
Last Progress Report
Current Status
Measurable Goal
Date:
Date:
Most Critical to Recovery
(Objective, Measurable, Timeframe)
(example)
Lifting: knee to chest level 10 lbs x 1 rep
20 lbs x 5 reps
30 lbs x 5 reps
30 lbs x 10 reps by February 1, 2006
2. Return to Work:
What is your current professional estimate of the worker’s potential to physically perform the job of injury?
Very Likely
Somewhat Likely
Not Likely
Describe any barriers to recovery that you have identified:
If the worker will not be returning to job of injury, has an alternative job goal been identified by the worker?
YES
NO
Don’t know
If YES, what is the goal? __________________________________________________________________
N/A (worker planning to return to job of injury)
Do you have a copy of the physical demands of this worker’s job (of injury or new goal) for reference?
YES
NO
3. Status of care
To date, is the worker actively engaged in the Plan of Care?
YES
NO (Please explain, e.g., understands home exercise program, consistent
attendance, participation in clinical program).
Is the worker continuing to make meaningful, functional progress according to your clinical plan of care?
YES
NO
Please describe your treatment plan and goals for the next set of treatments, including frequency and duration:
Estimated date that worker will be discharged from therapy: ___________
4. Comments
5. Signature of Therapist: _________________________________________________ Date: ________________
Clinic: _______________________________ City: __________________________ Phone: ____________________
F245-059-000 pt/ot progress report to claim managers 06-2006