Scale of Fees > Annual Increase in Medical Tariffs for Medical Service Providers - 2019 > Physiotherapist, Occupational Therapy and Chiropractor 2019 > Physiotherapy Services > Physiotherapy Rehabilitation progress report

Claim number:

Physiotherapy Rehabilitation progress report

Compensation for Occupational Injuries and Diseases Act, 1993

(Act No. 130 of 1993)

PART 1 - INITIAL VALUATION AND PLAN

Submit with first account

Names and Surname of Employee

Identity Number Address

Postal Code

Name of Employer

Address

Postal Code

Date of Accident Date of referral

Name of referring medical practitioner

Name of Physiotherapist

Practice Number

Physiotherapy Account number

1.	Date of first treatment

2.	Initial clinical presentation

3.	Describe patient's symptoms and functional status

4.	Are there any complicating factors that may prolong rehab or delay recovery (specify)?

5.	Overall goal of treatment

6.	Treatment Plan for proposed treatment session

Signature of Physiotherapist Date

Claim number: ................................

Physiotherapy Rehabilitation progress report

Compensation for Occupational Injuries and Diseases Act, 1993

(Act No. 130 of 1993)

PART 2 - TREATMENT AND PROGRESS (Monthly)

Submit on a monthly basis attached to the submitted accounts)

Names and Surname of Employee

Identity Number Address

Postal Code

Name of Employer

Address

Postal Code

Date of Accident Date of referral

Name of referring medical practitioner

Name of Physiotherapist

Practice Number

Physiotherapy Account number

1.	Number of Sessions (dates) already delivered? From To

2.	Progress achieved

3.	Did the patient undergo surgical procedures during this treatment period?

Dates of surgical procedures

4.	Number of sessions (dates) still required

5.	Treatment plan for proposed treatment sessions

Signature of Physiotherapist Date

Claim number:

Physiotherapy Rehabilitation progress report

Compensation for Occupational Injuries and Diseases Act, 1993

(Act No. 130 of 1993)

PART 3 - FINAL PROGRESS REPORT

Submit with final account

Names and Surname of Employee

Identity Number Address

Postal Code

Name of Employer

Address

Postal Code

Date of Accident Date of referral

Name of referring medical practitioner

Name of Physiotherapist

Practice Number

Physiotherapy Account number

Date of final treatment Number of treatment Dates

Progress achieved

From what date has the employee been fit for his/her normal work?

Is the employee fully rehabilitated/has the employee obtained the highest level of function?

If not, describe in detail any present permanent anatomical defect and/or impairment of function as a result of the accident (R.O.M., if applicable, must be indicated in degrees at each specific joint)

Signature of Physiotherapist Date