Treatment and progress summary
In line with the Clinical Framework provide details on the evidence based treatments provided or rationale for treatment being provided and a brief summary of the injured workers progress. For ongoing summaries please specify whether the injured worker's mental state has improved, remained the same or deteriorated.
This section details your plans for management of the injured worker. As per the Clinical Framework is it vital to ensure that there is alignment between treatment strategies and both the work related injury and the evidence base for treatment of that injury.
You can also provide further detail of any potential factors causing a deterioration of mental state.
Provide details of any standardised outcome measures you have used including dates and scores at each point in time.
Provide details on outcome measures that you have completed both at baseline and reassessment.
The Clinical Framework states that treatment provided to injured workers should result in a measureable benefit. This measurement should be conducted using standardised outcome measurement tools that are reliable, valid and sensitive to change.
Baseline measurements should be taken as soon as possible once treatment has commenced and repeated regularly to monitor progress.
The outcome measure(s) that you select should reflect the functional goals that you have identified with the injured worker. Some outcome measures that may be appropriate include, but are not limited to:
- World Health Organisation Disability Assessment Schedule (WHODAS)
- Health of the Nation Outcome Scales (HoNOS)
- Hospital Anxiety and Depression Scale (HADS)
- Distress Thermometer (DT)
- Kessler-10 plus (K10+)
- Multidimensional Scale of Perceived Social Support (MSPSS)
- World Health Organisation Well Being Scale – 5 (WHO-5)
- Client Engagement Scale (CES)
Barriers to recovery
Please detail any barriers you have identified that have the potential to impact the injured worker. These may be physical, personal and/or environmental barriers that have/will influence the workers return to work and recovery.
Please provide details here of any factors that you believe may impact the injured worker in regards to any of the following:
- ability to participate in treatment
- progression towards identified goals
- return to health
- return to work
Consider the injured worker holistically and assess potential biopsychosocial factors to may be impacting them.
It is also important to consider and describe how to reduce/address there barriers if within your scope of practice.
Consider any identified flags or risk factors (red, orange, yellow, blue, black – see the Clinical Framework)
Proposed management plan - Goal setting
Goals should be Specific, Measurable, Achievable, Relevant and Timed (SMART) and developed in collaboration with the injured worker.
Please provide details of SMART goals that you have identified in collaboration with the injured worker. It is vital that the injured worker has input into these goals and is in agreement.
SMART goals are Specific, Measurable, Achievable, Relevant and Timed. These goals should also be meaningful to the injured worker.
Goals do not all have to relate to return to work. Functional goals and return to health goals should be considered also.
Proposed ongoing treatment plan
Provide details to support your plan for ongoing intervention. This includes the expected number of treatment hours to achieve listed SMART goals.
This section is used to detail your proposed plan for ongoing management of the injured worker.
Please include information on how many hours of treatment you believe will be required to achieve the SMART goals specified in the above section.
List other treating practitioners who have been contacted
Please indicate if the referring medical practitioner along with other members of the treatment team have been contacted and provided with an update or a discussion has taken place regarding the progress of the injured worker. As per the policy and service standards communication with the referrer and other members of the injured worker's treatment team is vital.
Any other considerations or comments
This section can detail any other details that are relevant and need to be updated to the Agent or considered in the planning and ongoing management of the injured worker.