II. Indications

  1. Define occupation specific limitations related to Impairments

III. History

  1. Demographics
    1. Age
    2. Educational background and capability
    3. Social factors
  2. Job requirements and employee capabilities
    1. Specific tasks required for a patient's job
    2. Which of the required tasks can the patient perform
    3. Has the patient reached a maximal medical therapy
      1. In effect, are Impairments limiting current tasks improved to an expected level

IV. Approach

  1. Initial Evaluation Review
    1. Identify the third party who is making the Disability request and the indication (e.g. legal, employment, insurance)
    2. Identify the medical provider's role (e.g. consultant, treatment, independent medical examiner)
    3. Identify the key issues to be addressed and the applicable guidelines (e.g. FMLA, SSI)
    4. Obtain patient consent for release of information, fees and follow HIPAA regulations
  2. Diagnoses and Impairments
    1. See Functional Capacity Evaluation
    2. Identify physical and mental diagnoses and Impairments
    3. Use validated functional tools (including patient-reported outcome tools)
  3. Activity Limitations and Participation Restrictions
    1. Obtain job descriptions and understand the specific tasks an employee is expected to perform
    2. Apply limitations and restrictions based on the employee's ability to perform specific required activities
    3. Restrictions should be consistent and reasonable
  4. Assessment and Plan
    1. Maintain accurate and timely documentation, and conclusions should be consistent with objective evaluation
    2. Make use of electronic forms with consistent data when possible
    3. Include regular follow-up visits for reassessment and actvity modification when work restrictions are recommended
    4. Assigning causality and apportionment (percent permanent Disability) often requires Consultation
    5. Avoid permanent Disability assignments until all rehabilitation activities have been completed
  5. Assign Codes and Charges
    1. Assessments requested by third parties are billed separately from a patient's private insurance
    2. Documentation for third party requested evaluation (e.g. Worker Compensation) should be in its own progress note
    3. Consider time-based coding when completing forms, evaluating Disability and communicating with consultants

V. Types: Classifications

  1. Behavior
  2. Communication
  3. Body Disposition
  4. Personal care
  5. Locomotion
  6. Dexterity
  7. Situational
  8. Skill

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Ontology: Disability Evaluation (C0012605)

Definition (MSH) Determination of the degree of a physical, mental, or emotional handicap. The diagnosis is applied to legal qualification for benefits and income under disability insurance and to eligibility for Social Security and workmen's compensation benefits.
Definition (PSY) Evaluation of one's ability to work in order to determine the need for insurance or health benefits.
Concepts Diagnostic Procedure (T060)
MSH D004185
English Disability Evaluation, Disability Evaluations, Evaluation, Disability, Evaluations, Disability, disability evaluation, disability evaluations, Disability evaluation
Swedish Funktionshinderbedömning
Czech pracovní neschopnost - posuzování, invalidita - posuzování, neschopnost - posuzování
Finnish Haitta-astearviointi
French Évaluation du handicap, Évaluation de l'incapacité
Russian INVALIDNOSTI STEPENI OTSENKA, NETRUDOSPOSOBNOSTI OTSENKA, ИНВАЛИДНОСТИ СТЕПЕНИ ОЦЕНКА, НЕТРУДОСПОСОБНОСТИ ОЦЕНКА
Croatian INVALIDNOST, OCJENJIVANJE
Polish Ocena inwalidztwa, Ocena niepełnosprawności, Ocena stopnia niepełnosprawności
Norwegian Bedømming av funksjonshemming, Bedømming av funksjonsnedsettelse
German Behinderungseinstufung, Behinderungsgradfeststellung, Invaliditätsbeurteilung
Dutch Invaliditeitsschatting
Portuguese Avaliação da Deficiência
Italian Valutazione di invalidità
Spanish Evaluación de la Discapacidad