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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 ServicesOccupational Therapy ServicesRehabilitation Progress Report |
Claim Number: ................................
Rehabilitation progress report
Compensation for Occupational Injuries and Diseases Act, 1993
(Act No. 130 of 1993)
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.