II. Indications
- Define occupation specific limitations related to Impairments
III. History
- Demographics
- Age
- Educational background and capability
- Social factors
- Job requirements and employee capabilities
- Specific tasks required for a patient's job
- Which of the required tasks can the patient perform
- Has the patient reached a maximal medical therapy
- In effect, are Impairments limiting current tasks improved to an expected level
IV. Approach
- Initial Evaluation Review
- Identify the third party who is making the Disability request and the indication (e.g. legal, employment, insurance)
- Identify the medical provider's role (e.g. consultant, treatment, independent medical examiner)
- Identify the key issues to be addressed and the applicable guidelines (e.g. FMLA, SSI)
- Obtain patient consent for release of information, fees and follow HIPAA regulations
- Diagnoses and Impairments
- See Functional Capacity Evaluation
- Identify physical and mental diagnoses and Impairments
- Use validated functional tools (including patient-reported outcome tools)
- Activity Limitations and Participation Restrictions
- Obtain job descriptions and understand the specific tasks an employee is expected to perform
- Apply limitations and restrictions based on the employee's ability to perform specific required activities
- Restrictions should be consistent and reasonable
- Assessment and Plan
- Maintain accurate and timely documentation, and conclusions should be consistent with objective evaluation
- Make use of electronic forms with consistent data when possible
- Include regular follow-up visits for reassessment and actvity modification when work restrictions are recommended
- Assigning causality and apportionment (percent permanent Disability) often requires Consultation
- Avoid permanent Disability assignments until all rehabilitation activities have been completed
- Assign Codes and Charges
- Assessments requested by third parties are billed separately from a patient's private insurance
- Documentation for third party requested evaluation (e.g. Worker Compensation) should be in its own progress note
- Consider time-based coding when completing forms, evaluating Disability and communicating with consultants
V. Types: Classifications
- Behavior
- Communication
- Body Disposition
- Personal care
- Locomotion
- Dexterity
- Situational
- Skill