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Compensation for Occupational Injuries and Diseases Act, 1993 (Act No. 130 of 1993)Scale of FeesAnnual Increase in Medical Tariffs for Medical Service Providers - 2019Physiotherapist, Occupational Therapy and Chiropractor 2019Physiotherapy ServicesPhysiotherapy Rehabilitation progress report |
Claim number:
Physiotherapy Rehabilitation progress report
Compensation for Occupational Injuries and Diseases Act, 1993
(Act No. 130 of 1993)
PART 1 - INITIAL VALUATION AND PLAN
Submit with first account
Names and Surname of Employee
Identity Number Address
Postal Code
Name of Employer
Address
Postal Code
Date of Accident Date of referral
Name of referring medical practitioner
Name of Physiotherapist
Practice Number
Physiotherapy Account number
1. | Date of first treatment |
2. | Initial clinical presentation |
3. | Describe patient's symptoms and functional status |
4. | Are there any complicating factors that may prolong rehab or delay recovery (specify)? |
5. | Overall goal of treatment |
6. | Treatment Plan for proposed treatment session |
Signature of Physiotherapist Date
Claim number: ................................
Physiotherapy Rehabilitation progress report
Compensation for Occupational Injuries and Diseases Act, 1993
(Act No. 130 of 1993)
PART 2 - TREATMENT AND PROGRESS (Monthly)
Submit on a monthly basis attached to the submitted accounts)
Names and Surname of Employee
Identity Number Address
Postal Code
Name of Employer
Address
Postal Code
Date of Accident Date of referral
Name of referring medical practitioner
Name of Physiotherapist
Practice Number
Physiotherapy Account number
1. | Number of Sessions (dates) already delivered? From To |
2. | Progress achieved |
3. | Did the patient undergo surgical procedures during this treatment period? |
Dates of surgical procedures
4. | Number of sessions (dates) still required |
5. | Treatment plan for proposed treatment sessions |
Signature of Physiotherapist Date
Claim number:
Physiotherapy Rehabilitation progress report
Compensation for Occupational Injuries and Diseases Act, 1993
(Act No. 130 of 1993)
PART 3 - FINAL PROGRESS REPORT
Submit with final account
Names and Surname of Employee
Identity Number Address
Postal Code
Name of Employer
Address
Postal Code
Date of Accident Date of referral
Name of referring medical practitioner
Name of Physiotherapist
Practice Number
Physiotherapy Account number
Date of final treatment Number of treatment Dates
Progress achieved
From what date has the employee been fit for his/her normal work?
Is the employee fully rehabilitated/has the employee obtained the highest level of function?
If not, describe in detail any present permanent anatomical defect and/or impairment of function as a result of the accident (R.O.M., if applicable, must be indicated in degrees at each specific joint)
Signature of Physiotherapist Date