Fillable Physical Therapy / Occupational Therapy Progress Report To Claim Managers (Page 2 of 2) in pdf

PHYSICAL THERAPY / OCCUPATIONAL THERAPY PROGRESS REPORT TO CLAIM MANAGERS

Instructions for Completing this Form

Purpose: Labor and Industries (L&I) claim managers are responsible for supporting and managing all aspects

of an injured worker’s claim. The information in this report will clearly identify the clinical goals and return to

work objectives. Use of the form is NOT required, but inclusion of all the elements in your progress reports will

simplify review/authorization processes.

Please use black ink and type or print legibly. Do not disrupt your current plan of care unless you

have specifically been advised that continued treatment is not authorized. The claim manager may

contact you directly if there are additional questions about this injured worker’s care.

Identifying Information:

Diagnosis: Indicate the accepted condition(s) being treated within the therapy plan of care.

Report for dates of service: Indicate the start and end date for services covered in this report. The

start date would typically be the date of the last report.

Number of Visits: Count visits from initial evaluation through the most recent visit including pre/post

surgical care for this condition. Indicate the number of cancellations and/or no-shows.

Date of latest referral: Date of your most current referral or consultation with the attending

Note: the AP may be deferring to a specialist for therapy instructions, but it is your

physician (AP).

responsibility to be sure the orders for therapy are from the AP.

1. Measures most critical to recovery: List the physical limitations and the parameters you are using to

measure progress, including functional limitations. Document baseline and interim measurements. Goals

must include objective, measurable parameters and an estimated timeframe. When there are more

measures than there is space available, please list the measures that are most relevant to the

documentation of functional progress and/or job demands.

2. Return to work: It is important that both you and the worker are anticipating that the end result of

therapy is a return to work. Providing concise information based on clinical observation and physical

demands of the job goal will help the claim manager address this important issue. If needed, contact the

claim manager to see if a job analysis is available.

3. Status of Care: Use this section to help the claim manager understand how involved the worker is in the

recovery process and your professional opinion about the worker’s progress. Include issues such as

attendance, home exercise program, participation in clinical program, etc. Briefly describe your treatment

plan (including frequency and duration) and any changes in goals for the next set of treatments. Clearly

indicate when you estimate that therapy will be concluded.

4. Comments: Elaborate on any part of the care that needs explanation.

5. Signature: The legible signature of the therapist responsible for the plan of care, the name and phone

number of the clinic in which services are provided (including the city if part of a larger group of clinics),

and the date the report was completed.

This report can be mailed to the department (Dept. Labor and Industries, PO Box 44291, Olympia, WA, 98504-

4291), or it may be faxed to any of the following numbers:

360-902-4566

360-902-4567

360-902-5230

360-902-6460

360-902-4292

360-902-4565

360-902-6252

360-902-6100

F245-059-000 pt/ot progress report to claim managers 06-2006

Physical Therapy / Occupational Therapy Progress Report To Claim Managers Page 2

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