PSYCHOLOGY REVIEW FORM

Transcription

1 PS109 FORM - AGENT COPY PAGE 1 of 2 Review Date PATIENT DETAILS Patient s name WorkCover claim number Date of birthdate of injury Date of initial psychology treatment provided 1) by you 2) by another Total number of psychology consultations to date (see notes) Outline of psychology treatment provided to date (see notes) Describe the initial claimable injury and its relationship to the psychological condition (see notes) Since the initial previous review, the patient s condition has Improved Remained Stable Deteriorated Describe the current psychological condition including diagnosis and major symptoms (see notes) Current short term functional goals (see notes) 1 2 If acceptable what is impeding (or may impede) recovery (see notes) 3 Proposed psychology treatment plan and management strategies (see notes) FOR545/02/05.02

2 PS109 FORM - AGENT COPY PAGE 2 of 2 Estimated duration of treatment Short term (0-10 ) Medium term (11-20 ) Long term (21 plus) Estimated number of sessions in this period What liaison is required in order to ensure that optimum outcomes are achieved for your patient? (see notes) WORK STATUS AND ANTICIPATED OUTCOME If your patient has not returned to pre-injury work status, outline strategies to facilitate return to work PSYCHOLOGIST DETAILS Treating psychologist s name and address Telephone Fax Predicted work potential by end of treatment WorkCover Provider Number By when (see notes) Treating psychologist s signature Date (If return to work doesn t appear to be a possible outcome describe other long term goals and estimated time to achievement see notes) CONSENT I consent to the collection and use of personal and health information about me by the VWA, its Authorised Agents and self insurers for the purposes outlined in the statement entitled Collection of Personal and Health Information included with this form and I authorise the VWA, its Authorised Agents and self insurers to disclose such information to the types of organisations listed in the statement for any of those purposes. Signature of patient, parent or guardian Date Full name (please print)

3 PS109 FORM - PSYCHOLOGIST COPY PAGE 1 of 2 Review Date PATIENT DETAILS Patient s name WorkCover claim number Date of birthdate of injury Date of initial psychology treatment provided 1) by you 2) by another Total number of psychology consultations to date (see notes) Outline of psychology treatment provided to date (see notes) Describe the initial claimable injury and its relationship to the psychological condition (see notes) Since the initial previous review, the patient s condition has Improved Remained Stable Deteriorated Describe the current psychological condition including diagnosis and major symptoms (see notes) Current short term functional goals (see notes) 1 2 If acceptable what is impeding (or may impede) recovery (see notes) 3 Proposed psychology treatment plan and management strategies (see notes) FOR545/02/05.02

4 PS109 FORM - PSYCHOLOGIST COPY PAGE 2 of 2 Estimated duration of treatment Short term (0-10 ) Medium term (11-20 ) Long term (21 plus) Estimated number of sessions in this period What liaison is required in order to ensure that optimum outcomes are achieved for your patient? (see notes) WORK STATUS AND ANTICIPATED OUTCOME If your patient has not returned to pre-injury work status, outline strategies to facilitate return to work PSYCHOLOGIST DETAILS Treating psychologist s name and address Telephone Fax Predicted work potential by end of treatment WorkCover Provider Number By when (see notes) Treating psychologist s signature Date (If return to work doesn t appear to be a possible outcome describe other long term goals and estimated time to achievement see notes) CONSENT I consent to the collection and use of personal and health information about me by the VWA, its Authorised Agents and self insurers for the purposes outlined in the statement entitled Collection of Personal and Health Information included with this form and I authorise the VWA, its Authorised Agents and self insurers to disclose such information to the types of organisations listed in the statement for any of those purposes. Signature of patient, parent or guardian Date Full name (please print)

5 NOTES This form is to be completed by the treating Psychologist on request of the Agent. The item code for the review of the patient and completion of this report is PS109. Please also attach any additional information that would assist in understanding your patient and their treatment needs. REVIEW DATE The date on which the review for the completion of the Psychology Review form occurred. Initial Injury Provide brief details of the initial injury leading to your patient s claim. If the initial injury was not primarily psychological describe the relationship between the initial injury and the current psychological condition. Current psychological condition Include diagnosis (according to DSM-IV) and a brief description of the major symptoms. Some comparison should be made regarding your patient s current condition and problems as compared to the situation at the time of last review (or initial treatment notification). Factors impeding recovery Describe any crucial non-clinical issues which are affecting recovery. This might include both current and historical factors. Eg. perception that there is a lack of support within the work environment lack of appropriate plans for return to work or re-training In this section by another refers to consultations provided by any other psychologist prior to, or on an occasional concurrent basis (to the best of your knowledge). If you are aware of the number of consultations provided by another psychologist please include this alongside your own total. Outline of psychology treatment provided to date. Brief description of the treatment techniques and approaches used, self management strategies implemented and utilised etc. The matters identified here are to be taken as proposals only. It is recognised that circumstances may influence achievement of the goals and practices identified. Short term goals Relate your patient s current psychological condition to appropriate measurable goals that are associated with your patient s psychological coping and the restoration of capacity in activities of daily living and/or work function. Eg. to increase concentration span to...by reducing the impact of pain symptoms to develop skills to negotiate with employer over appropriate RTW duties. to increase number of sleep hours to...through relaxation techniques. to be able to travel to the workplace by car/public transport. to reduce/eliminate the occurrence of panic attacks. to return to the workplace on modified duties/partial hours etc to control analgesic medication to a regular pattern/lessen quantity etc. Measurable goals should be identified in conjunction with your patient and should be realistic, related to your patient s needs, and achievable within a short time frame. Estimate the time frame in which you believe your patient could reasonably be expected to achieve the goals set. Proposed psychology treatment plan Describe 1) the current and planned treatment 2) the method of implementing and reinforcing self management strategies, and 3) the need for referral to other health professionals and other necessary developments. WORK STATUS & ANTICIPATED OUTCOME are a modification of the worker s normal duties. are different work tasks/job. If a worker normally works part time, his/her return to normal work should be listed as part-time/normal duties. Predicted work potential With due regard to the normal clinical course of your patient s condition, estimate his/her work potential and when you expect this to be achieved Strategies to facilitate return to work This may involve communication with employer with regard to alterations or modifications to work duties and environs, the use of other interventions or treatments, and further progression of self management strategies. When return to work doesn t appear to be an achievable goal describe other long term goals and the anticipated achievement date. Liaison Identify who it would be appropriate to liaise with in order to achieve an optimum outcome for your patient. CONSENT INFORMATION The treating practitioner is legally responsible for obtaining the patient s consent for disclosure of information where necessary. Maintaining an open channel of communication between Agent, patient and practitioner is crucial to achieving the best outcome possible for the patient. The treating practitioner plays a vital role in helping their patient understand this concept. If your patient refuses to sign this form and thus prevents the disclosure of information, difficulties may arise regarding ongoing payment for services. This issue should be discussed with your patient. The relevant Agent should then be notified. COLLECTION OF PERSONAL AND HEALTH INFORMATION Personal and health information collected on this form and in the course of providing the treatment or other service is collected for the purposes of managing your claim, monitoring the treatment that you are receiving and assessing your future treatment needs. It may also be used for other purposes related, or in the case of health information, directly related, to these purposes, including for the purposes of legal proceedings arising out of the Accident Compensation Act Personal and health information collected about you may be disclosed to VWA; its Authorised Agent or self insurer; to their contractors, agents and legal practitioners; to medical or legal practitioners treating or acting for you in relation to your claim; to a court or tribunal in the course of any proceedings under the Act; and to any person or organisation authorised by you, or by law, to obtain it.