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CEC Associates, Inc.:
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1996
CEC Associates, Inc. All rights reserved. No part of these materials may be
reproduced without permission from CEC Associates, Inc., P.O. Box 987, Valley
Forge, Pennsylvania, 19482. (610) 935-7560.
(1) Injured Worker’s Name:
Employee’s
Personal Information: Address:
Home Telephone:
Nearest Relative:
Address/Telephone No.:
Employee’s Supervisor: Treatment Data: Treating Physician(s): Address:
Telephone Number:
Treating Facility(ies):
(2) In many states, the employer is required by Workers’ Compensation law or other relevant statutes to create an initial accident report. If such a report is available, attach it here. If it is not available, write an accident report. (A sample form is attached below.) Company Name Company Address Accident Report Name: Employee No. Department ______ Date of injury Time of injury ______ Date reported
Time reported
______ Last day worked Date returned to work ______ Location of accident
Description of accident:
Describe injuries:
Was Medical Care Administered? yes no Doctor
Hospital Address City
Telephone Treatment: Witnesses: __________________ Signature: ______________________________ Date: _____________ Initial
Diagnosis/Prognosis: Diagnosis by: Date: ___________
Prognosis by:
Date:
Diagnosis:
Prognosis:
Expected date of return to work: Recommendation concerning level of work intensity on return (i.e., modified duty, transitional duty, full duty):
Initial Treatment Report: (Describe what actions were taken to obtain medical attention for the employee immediately after the accident.)
(3) Event:
Date: ____________ Treatment Recommendation:
Event:
Date: Treatment Recommendation:
Event:
Date: Treatment Recommendation:
Event: Date: ____________
(4) Describe the stages of the recovery process that are planned for the employees, including target dates for each milestone. The Plan should end with a Transition-to-Work Plan and appropriate (projected) dates.
The general treatment milestones and the projected timeframe for each (to include types of therapies [speech, occupational, aqua, etc.], if appropriate): Treatment:
Description: Date: Treatment:
Description: Date: Treatment:
Description: Date: Treatment:
Description: Date: Treatment:
Description: Date:
(5) Obtain all medical records and place chronologically in the medical file. Specifically obtain and place all radiology reports in the file. Notes: 1. Although in most states a patient authorization is not required for the release of medical records, it is helpful to obtain such a release as soon as possible following the reported injury. Many facilities now require a signed authorization within six (6) months of the treatment date before they will release requested records. 2. All medical records are required by the Americans with Disabilities Act (and in some cases, other laws) to be isolated from personnel records and unavailable for most general personnel uses. One exception to the privacy of medical records is the supervisor’s need to know about any condition that may pose a direct threat to either the individual or others in the workplace.
Prescriptions and Referrals: Copies of all prescriptions for therapies and medications and/or referrals for additional/ supplemental treatments are to be placed in the Medical File. It is important to note the professional’s signature and the name prescribing. If the prescription is not related to this specific injury, it should be so noted. If the follow-up appointments are attended by a company representative, we recommend using the Medical Appointment Synopsis form (see attached). The representative may complete this form and have the examiner sign after the examination. The form may also be forwarded prior to the examination if a representative does not attend to remind the examiner of the specific points which need to be addressed. (6) Patient name: Carrier: Claim #:
Address:
Diagnosis: Adjustor: Employer:
Test Recommended? yes no If yes, as follows: CAT Scan x-ray MRI Myelogram Bone Scan EKG
Other
Treatment Recommended? yes no If yes, as follows: PT/OT (circle) Home Exercise
Medication
Other
Expected Date to Return to Work:
1. Pre-injury position yes no 2. Modified position yes no 3. Job description reviewed yes no for (name of position) 4. FCE completed yes no Comments:
Next Scheduled Appointment Date:
Time
Signature of Physician: Date:
Physician’s Name and Address: _ ______ Name of Case Manager/Consultant: 1996 CEC
Associates, Inc. All rights reserved. No part of these materials may be
reproduced without permission from CEC Associates, Inc., P.O. Box 987, Valley
Forge, Pennsylvania, 19482. (610) 935-7560.
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