Form 8-10_WPNL_Nov10_2015.cdr

SEND BY FAX ONLY
CONTACT US AT:
VISIT US AT:
f 709.738.1479
f 1.866.553.5119
t 709.778.1000
t 1.800.563.9000
workplacenl.ca
Instructions for Completing
Physician's Report 8/10
A physician would complete this report for:
1. New injuries – The physician or worker believes the injury is work-related.
2. Recurrences – The injury may be a recurrence of a previous work-related injury.
3. Progress reporting – When there is a significant change in the worker’s: (1) condition; (2) treatment; or (3) return-towork status.
On the day of the visit:
Provide the employer's copy of the form 8/10 to the injured worker, who will then give it to the employer. Only sections
outlined in red are visible on the employer's copy.
Complete and legible reporting:
§
Reporting fees will not be paid for incomplete or illegible reports.
Please do not use a stamp for any information including physician's name, contact information or billing number. Stamps are
§
not permitted as this is a triplicate form. Information provided by stamp will not be visible on the worker and employer copies
of the form. Forms using stamps will be considered illegible.
Section B - Specific Information for Parts of Body Injured:
§
It is not necessary to provide the Mechanism of Injury information on reports subsequent to the initial report unless there
is a change in the information provided or additional information is available.
§
Coding is used in this section as outlined on the reverse of this sheet. Only one code box should be used for each code
entered, regardless if the code has one or two digits (see example below).
§
First, enter codes for Part(s) of Body and whether the injury pertains to the Left, Right or Center of the specified body
part(s), if applicable. If the code for the Part of Body is not on the code sheet, enter the code for Other and identify the
specific body part in the space below the code.
§
For each Part of Body, enter coding, as applicable, for Subjective Reports, Objective Findings, Diagnoses, Treatments,
Investigations*, and Assistive Devices*. When outlining the Examination and Treatment Plan, including all applicable
codes is important.
§
If the Subjective Report, Objective Finding, Diagnosis, Treatment, Investigation and/or Assistive Device is not included
on the code sheet, enter the code for Other. When using Other codes, also enter the Other code number and provide
details for that code in the Additional Comments box (box 8).
§
The Update Status boxes are used when completing progress reports. They are intended to provide updates on Subjective
Reports and Objective Findings from the previous visit. The Update Status is not required for initial reports of injury.
*Note: The Investigations category is only intended for referrals being made at the time of this visit. Recommendations for assistive
devices may also require completion of a Health Care Devices and Supplies Prescription form.
Section B Example
SECTION B - SPECIFIC INFORMATION FOR PARTS OF BODY INJURED
6
Mechanism of injury / incident:
Same as previously reported on the initial report.
Use codes from code sheet
7
Code
i.
Part of Body
22
Left
iii.
8
Left
Nose
Centre
Right
2
Right
3
4
1
11
C
C
Centre
2
3
10 92
29
Did this injury
aggravate a
Investigations Assist. Devices prior health issue?
Treatment plan
Objective Findings
1
Update Status
Left
Other:
Right
Update Status
90
Other:
Subjective Reports
1
Other:
ii.
Examination
use more than one code where necessary
4
Diagnoses
1
2
27
3
Treatments
1
2
1
2
1
20
C
1
A
Centre
2
ü
Yes
No
Don’t know
Are there other
issues affecting
the worker’s injury,
recovery and / or
disability?
ü
Yes
No
Don’t know
Update Status
Additional Comments - or - If you use any of the “other” codes above (except Part of Body), indicate the code # and provide details.
If yes to either of the above
please specify in Box 8.
9 2 - n e ga t i ve b owst ri n g te st
o
D e c re a s e d RO M - F. F. 4 0 o, E xt. 10 L + R Rot a t i o n N L + R F l ex i o n N
Points to note:
§
The second Part of Body in this example was not included on the code sheet. Therefore, code 90 is entered for Other
and Nose is written in the text box immediately below the Part of Body code.
§
Under Objective Findings for the first Part of Body, code 10 is used for decreased range of motion. The details related to
the decreased ROM are documented in the Additional Comments box.
§
Also under Objective Findings for the first Part of Body, code 92 is entered for Other and 92 - negative bowstring test is
written in the Additional Comments box to specify the details of the Other code.
§
No Update Status is provided for the negative bowstring test as this finding had not been previously reported.
Section C Specific Information for All Diagnoses
(pertaining to Section B):
§
Subsection 12 only applies to medications prescribed for the work injury and not medications related to non-work
related injuries or illnesses.
PHYSICIAN'S FORM 8/10
MUST BE FAXED ONLY
Toll free fax
1.866.553.5119
This information is collected under the authority of the Workplace Health, Safety and Compensation Act to determine
entitlement to benefits and manage the injured worker’s claim. If you have any questions about this, please
contact WorkplaceNL's Access to Information and Protection of Privacy (ATIPP) Coordinator at 1.800.563.9000.
Abdomen
Ankle
Arm
Brain
Cervical region
Chest
Coccyx
Ear
Elbow
Eye
Face
Finger
Foot
Forearm
Groin
Hand
Head
Heel
Hip
Knee
Lower leg
Lumbar region
Lumbosacral region
Lung, airways
Pelvis
Ribs
Sacroiliac region
Shoulder
Thigh
Thoracic region
Thoracolumbar region
Toe
Wrist
Other*
* Provide details in the
Other box located
under Part of Body
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
90
Part of Body
Burning
Difficulty sitting
Difficulty standing
Difficulty walking
Dizziness
Headache
Interrupted sleep
Numbness
Limited weight bearing
Pain (mild)
Pain (moderate)
Pain (severe)
Pain radiating
Stiffness
Tenderness
Tingling
Weakness
No subjective reports
Other*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
Upper limb neural tension test (-ve)
Wasting
Weakness
Wheezing
No objective findings
Other*
Physiotherapy and
Chiropractic use only
(Physician use only) (Provide details in box 8)
* Provide details in the Additional
Comments box
44
45
46
47
89
92
Objective Findings
8/10, 8/10c and PR Code Sheet
A
B
C
Resolution
Significant improvement
Moderate improvement
D
E
F
Mild improvement
No change
Worsening
Update status to be added for follow up on Subjective Reports and Objective Findings.
* Provide details in the
Additional Comments box
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
88
91
Subjective Reports
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Abrasion
Allergic reaction
Amputation
Asthma
Burn
Bursitis
Carpal tunnel syndrome
Chronic obstructive pulmonary disease
Contusion
Crush
Dermatitis
Disc injury
Dislocation
Epicondylitis
Fracture
Frozen shoulder
Hernia
Herniated disc
Infection
Inflammation
Laceration
Ligament sprain (1st)
Ligament sprain (2nd)
Ligament tear (3rd degree sprain)
Mechanical back pain
Meniscal tear
Muscle strain
Plantar fasciitis
Puncture
Radiculopathy
Repetitive strain
Rotator cuff impingement
Rotator cuff injury
Rotator cuff tear
Spinal cord injury
Spinal stenosis
Spondylolisthesis
Tendonitis
Tenosynovitis
Traumatic spondylolisthesis / lysis
Other*
* Provide details in the
Additional Comments box
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
93
Diagnosis
Acupuncture
Casting
Chiropractic
Cold
Conditioning exercises
Core stability exercises
Education
Heat
Home exercises
IFC
Laser
Manipulations
Massage
Mobilizations
Motion control
Muscle stimulation
Myofascial release
Occupational rehabilitation
Oxygen
Physiotherapy
Proprioception exercises
Range of motion exercises
Rest
SMT / adjustment
Soft tissue techniques
Steroid injections
Strengthening exercises
Stretching exercises
Suturing
TENS
Traction (manual)
Traction (mechanical)
Ultrasound
Other*
* Provide details in the
Additional Comments box
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
94
Treatments
Blood tests / U/A
Bone scan
CT scan
EMS / NCS
Ultrasound
X-ray
Other*
Ankle brace
Arch supports
Back brace
Back support
Bandage
Cane
Cast
Cervical collar
Cervical pillow
Cold pack
Corset
Crutches
Dressing
Heating pad
Orthotics
Prosthesis
Sling
Splint
Strap, band
Walker
Walking boot
Wheelchair
Other*
* Provide details in
the Additional
Comments box
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
96
Assistive Devices
1
2
3
4
5
6
95
Investigations
Effective Date: December 2015
Dec, 2015
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f 1.866.553.5119
t 709.778.1000
t 1.800.563.9000
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SECTION A - GENERAL INFORMATION (please print clearly)
1
Worker’s last name
2
Mailing address
Physician’s
Report
8/10
Claim #
Initial
First name
First name
Physician’s last name
WorkplaceNL billing #
Mailing address
Contact telephone
Province
Province
Date of birth
Postal code
3
MCP
4
Occupation
Gender
Reporting fee requested?
yyyy/mm/dd
Postal code
M
Yes
Telephone
F
MCP fee codes
Fax
Date / time of visit
Employer
No
yyyy/mm/dd
hh:mm
AM
PM
5
Date of injury / incident
Are you the primary
health care provider?
Did this injury develop
over time without a
specific injury / incident?
yyyy/mm/dd
Yes
No
Where did you
see the worker?
Yes
No
Is this an initial report of injury / incident?
Office
Emergency
Yes
No
SECTION B - SPECIFIC INFORMATION FOR PARTS OF BODY INJURED
6
Mechanism of injury / incident:
7
Use codes from code sheet
Code
i.
Part of Body
Other:
ii.
Other:
4
1
2
3
Diagnoses
4
1
2
Treatments
3
1
2
1
2
1
2
Yes
No
Don’t know
Centre
Right
Are there other
issues affecting
the worker’s injury,
recovery and / or
disability?
Centre
Update Status
Left
Other:
8
3
Update Status
Left
iii.
Right
2
Treatment plan
Objective Findings
Subjective Reports
1
Left
Did this injury
aggravate a
Investigations Assist. Devices prior health issue?
Examination
use more than one code where necessary
Right
Centre
Yes
No
Don’t know
Update Status
If yes to either of the above
please specify in Box 8.
Additional Comments - or - If you use any of the “other” codes above (except Part of Body), indicate the code # and provide details.
SECTION C - SPECIFIC INFORMATION FOR ALL DIAGNOSES (PERTAINING TO SECTION B)
9
10
Yes
No
Have you referred the worker to a specialist
other than the request in Question 9?
11
Have you prescribed opioids during this visit?
12
Did you add, discontinue or change
medications during this visit?
Interdisciplinary program
EMG/NCS
If yes, please
indicate:
Yes
No
Do you suggest WorkplaceNL
arrange any specialty appointments?
A referral letter
must be attached.
Neurosurgeon
Orthopaedic surgeon
If yes, Name _____________________________________
Date of appointment (if known)
yyyy/mm/dd
Specialty _________________________________________
Yes
No
Drug name
Dose
Status
1.
Add
Discontinue
Change
Yes - Complete table
at right
2.
Add
Discontinue
Change
No - Go to Section D
3.
Add
Discontinue
Change
Frequency
Quantity
Repeat
SECTION D - RETURN-TO-WORK STATUS
13
Explanation of current functional abilities check all that apply and specify details in the space provided
Worker has full functional abilities to return to work (please go to Section E)
Lifting restrictions, specify
< 10 lbs
< 20 lbs
Bending / twisting restrictions, specify
< 50 lbs
No bending / twisting
Avoid repetitive lifting
No lifting
Avoid repetitive bending / twisting
Standing restrictions, specify
Climbing (stairs / ladders) restrictions, specify
Kneeling / crouching restrictions, specify
Sitting restrictions, specify
Walking restrictions, specify
Upper extremity restrictions, specify
Restrictions due to medications, specify
Limitations due to environment, specify
Other limitations, specify
14
What are the recommended work hours?
15
Estimate duration of current functional abilities:
Pre-injury / incident
1 to 2 days
Other: _________ Should the hours be graduated?
3 to 7 days
8 to 14 days
Yes
No
15+ days
SECTION E - FOLLOW-UP
Yes
No
Yes
No
1 to 7 days
8 to 14 days
16
Have you reviewed the details
of this report with the worker?
17
Is a follow-up
appointment required?
18
I certify this is a complete and accurate report and I have received no prior payment from WorkplaceNL for this visit.
Yes
No
Have you provided a copy
of this report to the worker?
If yes, when should
the appointment occur?
Have you provided a copy of this report
to the worker to give to the employer?
15 to 21 days
22+ days
Do you want
WorkplaceNL to call you?
Yes
No
Yes
No
Date
yyyy/mm/dd
Signature
WHITE – PHYSICIAN’S COPY YELLOW – EMPLOYER’S COPY (WORKER TO DELIVER AND DISCUSS WITH EMPLOYER)
BLUE – WORKER’S COPY
Dec. 2015
SEND BY FAX ONLY
CONTACT US AT:
VISIT US AT:
f 709.738.1479
f 1.866.553.5119
t 709.778.1000
t 1.800.563.9000
workplacenl.ca
SECTION A - GENERAL INFORMATION (please print clearly)
1
Worker’s last name
2
Mailing address
8/10
Claim #
Initial
First name
First name
Physician’s last name
Mailing address
Contact telephone
Province
Province
Date of birth
Postal code
3
Gender
yyyy/mm/dd
Postal code
M
Telephone
F
Fax
Date / time of visit
Employer
Occupation
4
Physician’s
Report
yyyy/mm/dd
hh:mm
AM
PM
5
Date of injury / incident
Did this injury develop
over time without a
specific injury / incident?
yyyy/mm/dd
Are you the primary
health care provider?
Yes
No
Yes
No
Where did you
see the worker?
Is this an initial report of injury / incident?
Office
Emergency
Yes
No
SECTION B - SPECIFIC INFORMATION FOR PARTS OF BODY INJURED
6
Mechanism of injury / incident:
7
Use codes from code sheet
use more than one code where necessary
Code
i.
Part of Body
Left
Other:
ii.
Centre
Update Status
Left
Other:
iii.
Right
Right
Code details provided on reverse.
Centre
Update Status
Left
Other:
Right
Centre
Update Status
SECTION D - RETURN-TO-WORK STATUS
13
Explanation of current functional abilities check all that apply and specify details in the space provided
Worker has full functional abilities to return to work (please go to Section E)
Lifting restrictions, specify
< 10 lbs
< 20 lbs
Bending / twisting restrictions, specify
< 50 lbs
No bending / twisting
Avoid repetitive lifting
No lifting
Avoid repetitive bending / twisting
Standing restrictions, specify
Climbing (stairs / ladders) restrictions, specify
Kneeling / crouching restrictions, specify
Sitting restrictions, specify
Walking restrictions, specify
Upper extremity restrictions, specify
Restrictions due to medications, specify
Limitations due to environment, specify
Other limitations, specify
14
What are the recommended work hours?
15
Estimate duration of current functional abilities:
Pre-injury / incident
1 to 2 days
Other: _________ Should the hours be graduated?
3 to 7 days
8 to 14 days
Yes
No
15+ days
SECTION E - FOLLOW-UP
16
Have you reviewed the details
of this report with the worker?
17
Is a follow-up
appointment required?
18
I certify this is a complete and accurate report and I have received no prior payment from WorkplaceNL for this visit.
Yes
No
Yes
No
Yes
No
1 to 7 days
8 to 14 days
Have you provided a copy
of this report to the worker?
If yes, when should
the appointment occur?
Have you provided a copy of this report
to the worker to give to the employer?
Yes
No
15 to 21 days
22+ days
Date
yyyy/mm/dd
Signature
WHITE – PHYSICIAN’S COPY YELLOW – EMPLOYER’S COPY (WORKER TO DELIVER AND DISCUSS WITH EMPLOYER)
BLUE – WORKER’S COPY
SEND BY FAX ONLY
CONTACT US AT:
VISIT US AT:
f 709.738.1479
f 1.866.553.5119
t 709.778.1000
t 1.800.563.9000
workplacenl.ca
Supporting Information
Employers and workers are obligated under the Workplace Health, Safety and Compensation Act to co-operate in the worker's early and safe
return to suitable and available employment with the injury employer. This may involve modified work, ease back to regular work, transfer to an
alternate job, or trial work to assess the worker’s capability.
The worker is responsible for providing the employer's copy of the form 8/10, physician's report, to the employer by the next working day
following the physician's visit. If a worker cannot provide the form in person he/she must contact the employer and provide the information by
telephone, e-mail or fax.
Worker co-operation:
(i) contact the injury employer as soon as possible after the injury occurs and maintain effective communication throughout the period of
recovery or impairment;
(ii) assist the employer, as may be required or requested, to identify suitable and available employment;
(iii) accept suitable employment when identified; and
(iv) give WorkplaceNL any information requested concerning the return-to-work plan, including information about any disputes or
disagreements which arise during the early and safe return-to-work process.
Employer co-operation:
(i) contact the worker as soon as possible after the injury occurs and maintain effective communication throughout the period of the worker's
recovery or impairment;
(ii) provide suitable and available employment. The employer is responsible to pay the worker's salary earned during the early and safe
return-to-work plan. WorkplaceNL will pay the differential, if any, between the salary earned during the early and safe return-to-work plan
and 80% of the worker's net pre-injury earnings subject to the maximum compensable ceiling; and
(iii) give WorkplaceNL any information requested concerning the worker's return to work, including information about any disputes or
disagreements which arise during the early and safe return-to-work process.
Part of Body
1
2
3
4
5
6
7
8
9
10
Abdomen
Ankle
Arm
Brain
Cervical region
Chest
Coccyx
Ear
Elbow
Eye
11
12
13
14
15
16
17
18
19
20
Face
Finger
Foot
Forearm
Groin
Hand
Head
Heel
Hip
Knee
21
22
23
24
25
26
27
28
29
30
Lower leg
Lumbar region
Lumbosacral region
Lung, airways
Pelvis
Ribs
Sacroiliac region
Shoulder
Thigh
Thoracic region
31
32
33
90
Thoracolumbar region
Toe
Wrist
Other
Dec. 2015
SEND BY FAX ONLY
CONTACT US AT:
VISIT US AT:
f 709.738.1479
f 1.866.553.5119
t 709.778.1000
t 1.800.563.9000
workplacenl.ca
SECTION A - GENERAL INFORMATION (please print clearly)
1
Worker’s last name
2
Mailing address
Physician’s
Report
8/10
Claim #
Initial
First name
First name
Physician’s last name
Mailing address
Contact telephone
Province
Province
Date of birth
Postal code
3
MCP
4
Occupation
Gender
CODES FOR
SECTION B ON
REVERSE
yyyy/mm/dd
Postal code
M
Telephone
F
Fax
Date / time of visit
Employer
yyyy/mm/dd
hh:mm
AM
PM
5
Date of injury / incident
Are you the primary
health care provider?
Did this injury develop
over time without a
specific injury / incident?
yyyy/mm/dd
Yes
No
Where did you
see the worker?
Yes
No
Is this an initial report of injury / incident?
Office
Emergency
Yes
No
SECTION B - SPECIFIC INFORMATION FOR PARTS OF BODY INJURED
6
Mechanism of injury / incident:
7
Use codes from code sheet
Code
i.
Part of Body
Left
Other:
ii.
Other:
Subjective Reports
Objective Findings
1
1
2
3
4
2
3
Diagnoses
4
1
2
Treatments
3
1
2
1
2
1
2
Yes
No
Don’t know
Centre
Right
Are there other
issues affecting
the worker’s injury,
recovery and / or
disability?
Centre
Update Status
Left
Other:
8
Treatment plan
Update Status
Left
iii.
Right
Did this injury
aggravate a
Investigations Assist. Devices prior health issue?
Examination
use more than one code where necessary
Right
Centre
Yes
No
Don’t know
Update Status
If yes to either of the above
please specify in Box 8.
Additional Comments - or - If you use any of the “other” codes above (except Part of Body), indicate the code # and provide details.
SECTION C - SPECIFIC INFORMATION FOR ALL DIAGNOSES (PERTAINING TO SECTION B)
9
10
Yes
No
Have you referred the worker to a specialist
other than the request in Question 9?
11
Have you prescribed opioids during this visit?
12
Did you add, discontinue or change
medications during this visit?
Interdisciplinary program
EMG/NCS
If yes, please
indicate:
Yes
No
Do you suggest WorkplaceNL
arrange any specialty appointments?
A referral letter
must be attached.
Neurosurgeon
Orthopaedic surgeon
If yes, Name _____________________________________
Date of appointment (if known)
yyyy/mm/dd
Specialty _________________________________________
Yes
No
Drug name
Dose
Status
1.
Add
Discontinue
Change
Yes - Complete table
at right
2.
Add
Discontinue
Change
No - Go to Section D
3.
Add
Discontinue
Change
Frequency
Quantity
Repeat
SECTION D - RETURN-TO-WORK STATUS
13
Explanation of current functional abilities check all that apply and specify details in the space provided
Worker has full functional abilities to return to work (please go to Section E)
Lifting restrictions, specify
< 10 lbs
< 20 lbs
Bending / twisting restrictions, specify
< 50 lbs
No bending / twisting
Avoid repetitive lifting
No lifting
Avoid repetitive bending / twisting
Standing restrictions, specify
Climbing (stairs / ladders) restrictions, specify
Kneeling / crouching restrictions, specify
Sitting restrictions, specify
Walking restrictions, specify
Upper extremity restrictions, specify
Restrictions due to medications, specify
Limitations due to environment, specify
Other limitations, specify
14
What are the recommended work hours?
15
Estimate duration of current functional abilities:
Pre-injury / incident
1 to 2 days
Other: _________ Should the hours be graduated?
3 to 7 days
8 to 14 days
Yes
No
15+ days
SECTION E - FOLLOW-UP
16
Have you reviewed the details
of this report with the worker?
17
Is a follow-up
appointment required?
18
I certify this is a complete and accurate report and I have received no prior payment from WorkplaceNL for this visit.
Yes
No
Yes
No
Yes
No
1 to 7 days
8 to 14 days
Have you provided a copy
of this report to the worker?
If yes, when should
the appointment occur?
Have you provided a copy of this report
to the worker to give to the employer?
15 to 21 days
22+ days
Do you want WHSCC
to call you?
Yes
No
Yes
No
Date
yyyy/mm/dd
Signature
WHITE – PHYSICIAN’S COPY YELLOW – EMPLOYER’S COPY (WORKER TO DELIVER AND DISCUSS WITH EMPLOYER)
BLUE – WORKER’S COPY
SEND BY FAX ONLY
CONTACT US AT:
VISIT US AT:
f 709.738.1479
f 1.866.553.5119
t 709.778.1000
t 1.800.563.9000
workplacenl.ca
Supporting Information
Employers and workers are obligated under the Workplace Health, Safety and Compensation Act to co-operate in the worker's early and safe
return to suitable and available employment with the injury employer. This may involve modified work, ease back to regular work, transfer to an
alternate job, or trial work to assess the worker’s capability.
The worker is responsible for providing the employer's copy of the form 8/10, physician's report, to the employer by the next working day
following the physician's visit. If a worker cannot provide the form in person he/she must contact the employer and provide the information by
telephone, email or fax.
Worker co-operation:
(i)
contact the injury employer as soon as possible after the injury occurs and maintain effective communication throughout the period of
recovery or impairment;
(ii) assist the employer, as may be required or requested, to identify suitable and available employment;
(iii) accept suitable employment when identified; and
(iv) give WorkplaceNL any information requested concerning the return-to-work plan, including information about any disputes or
disagreements which arise during the early and safe return-to-work process.
Employer co-operation:
(i)
contact the worker as soon as possible after the injury occurs and maintain effective communication throughout the period of the worker's
recovery or impairment;
(ii) provide suitable and available employment. The employer is responsible to pay the worker's salary earned during the early and safe
return-to-work plan. WorkplaceNL will pay the differential, if any, between the salary earned during the early and safe return-to-work plan
and 80% of the worker's net pre-injury earnings subject to the maximum compensable ceiling; and
(iii) give WorkplaceNL any information requested concerning the worker's return to work, including information about any disputes or
disagreements which arise during the early and safe return-to-work process.
Part of Body
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
90
Abdomen
Ankle
Arm
Brain
Cervical region
Chest
Coccyx
Ear
Elbow
Eye
Face
Finger
Foot
Forearm
Groin
Hand
Head
Heel
Hip
Knee
Lower leg
Lumbar region
Lumbosacral region
Lung, airways
Pelvis
Ribs
Sacroiliac region
Shoulder
Thigh
Thoracic region
Thoracolumbar region
Toe
Wrist
Other
Objective Findings
Subjective Reports
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
88
91
Burning
Difficulty sitting
Difficulty standing
Difficulty walking
Dizziness
Headache
Interrupted sleep
Numbness
Limited weight bearing
Pain (mild)
Pain (moderate)
Pain (severe)
Pain radiating
Stiffness
Tenderness
Tingling
Weakness
No subjective reports
Other
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
(Physician use
only - provide
details in box 8)
Scar
Sensory loss
Spasm
Straight leg raise (Negative)
Straight leg raise (60+)
Straight leg raise (30-60)
Straight leg raise (0-30)
Strength (5/5)
Strength (4/5)
Strength (3/5)
Strength (2/5)
Strength (1/5)
Swelling
Upper limb neural tension test (+ve)
Upper limb neural tension test (-ve)
Wasting
Weakness
Wheezing
No objective findings
Other
Physiotherapy and
Chiropractic use only
Update status to be added for follow up on Subjective Reports and Objective Findings.
A
B
Resolution
Significant improvement
C
D
Moderate improvement
Mild improvement
Diagnosis
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
89
92
Abrasion
Allergic reaction
Amputation
Asthma
Burn
Bursitis
Carpal tunnel syndrome
Chronic obstructive pulmonary disease
Contusion
Crush
Dermatitis
Disc injury
Dislocation
Epicondylitis
Fracture
Frozen shoulder
Hernia
Herniated disc
Infection
Inflammation
Laceration
Ligament sprain (1st)
Ligament sprain (2nd)
Ligament tear (3rd degree sprain)
Mechanical back pain
Meniscal tear
Muscle strain
Plantar fasciitis
Puncture
Radiculopathy
Repetitive strain
Rotator cuff impingement
Rotator cuff injury
Rotator cuff tear
Spinal cord injury
E
F
No change
Worsening
Treatments
36
37
38
39
40
93
Spinal stenosis
Spondylolisthesis
Tendonitis
Tenosynovitis
Traumatic spondylolisthesis / lysis
Other
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
94
Acupuncture
Casting
Chiropractic
Cold
Conditioning exercises
Core stability exercises
Education
Heat
Home exercises
IFC
Laser
Manipulations
Massage
Mobilizations
Motion control
Muscle stimulation
Myofascial release
Occupational rehabilitation
Oxygen
Physiotherapy
Proprioception exercises
Range of motion exercises
Rest
SMT / adjustment
Soft tissue techniques
Steroid injections
Strengthening exercises
Stretching exercises
Suturing
TENS
Traction (manual)
Traction (mechanical)
Ultrasound
Other
Investigations
1
2
3
4
5
6
95
Blood tests / U/A
Bone scan
CT scan
EMS / NCS
Ultrasound
X-ray
Other
Assistive Devices
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
96
Ankle brace
Arch supports
Back brace
Back support
Bandage
Cane
Cast
Cervical collar
Cervical pillow
Cold pack
Corset
Crutches
Dressing
Heating pad
Orthotics
Prosthesis
Sling
Splint
Strap, band
Walker
Walking boot
Wheelchair
Other