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R 385
Compensation for Occupational Injuries and Diseases Act, 1993 (Act No. 130 of 1993)Scale of FeesAnnual Increase in Medical Tariffs for Medical Service Providers - 2018Physiotherapy Services, Occupational Therapy Services and Chiropractor ServicesChiropractor ServicesRehabilitation Progress Report |
Claim Number: ................................
REHABILITATION PROGRESS REPORT
COMPENSATION FOR OCCUPATIONAL INJURIES AND DISEASE ACT
Names and Surname of Employee
Identity Number Address
Postal Code
Name of Employer
Address
Postal Code
Date of Accident
1. | Date of first treatment Provider who provided first treatment |
2. | Initial clinical presentation and functional status |
3. | Name of referring medical practitioner Date of referral |
4. | Describe patient's current symptoms and functional status |
5. | Are there any complicating factors that may prolong rehabilitation or delay recovery (specify)? |
6. | Overall goal of treatment: |
7. Number of sessions already delivered Progress achieved
8. Number of sessions required Treatment plan for proposed treatment sessions
9. From what date has the employee been fit for his/her normal work?
10. | Is the employee fully rehabilitated/has the employee obtained the highest level of function? |
11. | If so, describe in detail any present permanent anatomical defect and/or impairment of function as a result of the accident (R.O.M, if any must be indicated in degrees at each specific joint) |
I certify that I have by examination, satisfied myself that the injury (ies) are as a result of the accident.
Signature of rehabilitation service provider
Name (Printed) Date (Important)
Address
Practice number
N.B. Rehabilitation progress reports must be submitted on a monthly basis and attached to the submitted accounts.