CHIROPRACTOR'S PROGRESS REPORT DISCHARGE by xyh75214

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									                                                           CHIROPRACTOR'S PROGRESS                                                                                    REPORT
      P.O. BOX 2415
                                                                          DISCHARGE
EDMONTON, ALBERTA T5J 2S5                                                                                                                  WCB Claim Number
FAX: (780) 427 - 5863
                                                                                        Time loss                No time loss              Personal Health Number

Please print.
                              Worker's Surname                                          Given Name                              Initial              Date of Birth       (Year / Month / Day)
(Black ink - press firmly)

Worker's Address                                                                           Postal Code                               Telephone Number
                                                                                                                                     (         )
1. Patient complaints (nature and sites of symptoms):                 Date of Accident        (Year / Month / Day)      2.         Patient Status and /or Discharge
                                                                                                                                  recommendations related to job requirements?



3. Objective findings (including current examination and              Date of Examination       (Year / Month / Day)
   relevant tests):




4. Describe changes in diagnosis        Diag Code                  Diag Code                Diag Code
   and/or status:



                                                                                                                           6.             Discharge Status (check one only)
5. General prognosis/remarks:                                                                                                   Employment / Pre-Accident Level
                                                                                                                                Employment / Modified Level
                                                                                                                                Not Employed / Capable of Pre-Accident Level
7. Does patient require:                                                                                                        Not Employed / Capable of Modified Level
   A) Assessment/treatment                                      B) An independent
     at a Rehabilitation Centre? No             Yes                examination?      No          Yes                            Further Investigation / Treatment
                                                                  Type or specialty:
                                                                                                                                Discharged due to Non-Compliance/Non-Attendance
8. Does patient                                         To whom:
   require a referral    No         Yes                                                                                         Other

9. X-Rays since                                         Type:                                                                                       10. TREATMENT DATES (MONTH/DAY)
   last report:          No         Yes
                                                        Interpretation:                                                                              wk   Day 1 Day 2 Day 3 Day 4 Day 5

   Facility:                                                                                                                                         1
11. Treatment plan:                             Frequency and duration:                                                                              2

                                                                                                                                                     3

                                                                                                                                                     4
12. Any complicating factors                                         Describe:
                                  No           Yes
    affecting recovery?                                                                                                                              5

                                                                                                                                                     6
13. Is injury preventing patient from performing                               Estimated date of return to                                     Date           (Year / Month / Day)
    pre-accident work? (if no, go to #15) No                Yes                pre-accident work:
14. Can "Modified or Alternate"                                                Describe work capability: (see over for definition)
    work be performed?                           No         Yes                Sedentary            Light              Medium                         Heavy          Very Heavy
15. Any work restrictions?                                                     Describe:
                                                 No         Yes

                              Permanent               Temporary                Duration:
16. Name and address of Chiropractor to whom fee is payable:                      Chiropractor's Signature:
(please print)


                                                                                 Date                    (Year / Month / Day)        Telephone Number
WCB Billing Number:                                                                                                                   (         )

                   THIS DOCUMENT MAY BE EXAMINED BY ANY PERSON WITH DIRECT INTEREST IN A CLAIM THAT IS UNDER REVIEW.
C-352 REV JAN 99        Des: Date of Service                PART 1 - WCB     PART - 2 HEALTH CARE SERVICES             PART 3 - CHIROPRACTOR
                                     REPORTING RESPONSIBILITIES

 1.          Chiropractor's First Report - must be submitted to the WCB the first time any Chiropractor
             attends a patient for work-related injury or illness, when:
             ·        No time is lost from work, but additional or ongoing treatment is required in all cases.
             ·        Time lost from work will extend beyond the day of accident.
             ·        Modified work beyond the date of accident required.
             ·        Permanent disability is involved or anticipated.

 2.          Chiropractor's Progress/Discharge Report must be submitted to the WCB as a Progress Report
             when:
             ·        When the worker is physically capable of returning to work, or within 48 hours of
                      actually returning to work.
             ·        The worker has completed three weeks of treatment if six weeks of treatment are
                      required.

 3.          Chiropractor's Progress/Discharge Report must be submitted to the WCB as a Discharge
             Report when:
             ·        The worker has completed treatment.




                                             WORK DEFINITIONS

 Modified                                                  Alternate
 •           a change in or adaptation of the date-of-
                                                           •        a different job with duties within the
             accident work, based on the worker's                   worker's capabilities.
             capabilities.
 •           may be temporary or permanent.



                                   WORK CAPABILITIES DEFINITIONS

 Sedentary                                                 Medium
                                                           •        Lifting 50 lbs. maximum
 •           Lifting 10 lbs maximum
 •           Occasional lifting and/or carrying            •        Frequent lifting and/or carrying up to 20
 •           Primarily sitting, with occasional                     lbs.
             walking/standing                              •        May involve sitting with pushing and pulling
                                                                    or arm and/or leg controls
 Light                                                     Heavy
                                                           •        Lifting 100 lbs. maximum
 •           Lifting 20 lbs. maximum
 •           Frequent lifting and/or carrying up to 10     •        Frequent lifting and/or carrying up to 50
             lbs.                                                   lbs.
 •           May require walking/standing to a
             significant degree                            Very Heavy
 •           May involve sitting with pushing and
             pulling of arm and/or leg controls            •        Occasional lifting in excess of 100 lbs.
                                                           •        Frequent lifting and/or carrying excess of
                                                                    50 lbs.


C-352 REV JAN 99

								
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