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Musculoskeletal Program of Care (MSK POC) Care &

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Country of origin: CANADA
File type: PDF

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Mail to:
200 Front Street W.
Toronto ON
M5V 3J1
Fax to:
416-344-4684 or
1-888-313-7373
Musculoskeletal
Program of Care (MSK POC)
Care & Outcomes Summary
Claim Number
For an injury to: (select one) Upper body (excluding the shoulder)
Lower body (excluding the lower back)
Please PRINT in black ink.
A. Worker Information
Last Name
First Name Initials
Date of Injury (dd/mmm/yyyy)
Date of Birth (dd/mmm/yyyy)
Worker completed MSK POC
Worker did not return / self discharged from MSK POC
B. Health Professional Information
WSIB Provider ID.
Chiropractor Physiotherapist Other
Health Professional Name Your Invoice No.
dd mmm yyyy
Facility Name Date of Discharge
Address (no. street, suite)
Service Code
MSKUCOS - upper body
(select one)
MSKLCOS - lower body
City/Town
Complete these fields if HST is applicable to this form
Service Code HST Amount Billed
HST Registration No.
Prov. Postal Code Telephone No.
ONHST $
C. Functional Information
1. Administer and record the scores for the Patient-Specific Functional Scale (PSFS) for 3-5 functional activities at least 2 of which are
work-related. The PSFS is available on the WSIB web site at www.wsib.on.ca.
Date of intial assessment (dd/mmm/yyyy) Date of final assessment (dd/mmm/yyyy)
Scores
at initial
Assessment
Scores
at final
Assessment
Relevant Physical
Demands/Functional
requirements
Clinician’s Assessment
of Current Ability
Functional Activity
E.g. Lift from floor level Lift 30 lb box from floor to hip level,
using both hands.
Can lift 30 lb box but is slower
than usual.
3/10 9/10
/10 /10
1.
/10 /10
2.
/10 /10
3.
/10 /10
4.
/10 /10
5.
Total: Divide the total score by
the number of activities
(minimum of 3 activities)
/10 /10
2339A (01/14)
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Musculoskeletal
Program of Care (MSK POC)
Care & Outcomes Summary
Worker's Last Name Worker's First Name
Date of Birth (dd/mmm/yyyy) Date of Injury (dd/mmm/yyyy)
Claim Number
C. Functional Information (cont'd)
2. Have you identified any factors that may delay recovery or Return to Work? Yes No
If yes, please describe:
D. Clinical Information
1. Change in pertinent clinical signs:
2. Other relevant clinical information:
E. Return to Work Information
1. a. At discharge is the worker able to perform all regular work duties and work hours? Yes No
b. This has been communicated with the worker.
2. a. If this worker is not able to perform all regular work duties and work hours, indicate the type of contact you had with WSIB.
Verbal Written None Call confirmation number:
b. Name of WSIB contact Date of contact (dd/mmm/yyyy)
3. What are your recommendations for work activities?
Regular duties
Yes No If no, enter expected date (dd/mmm/yyyy)
If no, enter expected date (dd/mmm/yyyy)
Modified duties Yes No
Regular hours Yes No If no, enter expected date (dd/mmm/yyyy)
Modified hours
Yes No
If no, enter expected date (dd/mmm/yyyy)
4. Has the worker returned to all regular work duties and all regular work hours? Yes No
Comments
F. Summary of Care Delivered
1. Date of last visit (dd/mmm/yyyy) 2. Indicate the total number of visits:
3. Program of Care Interventions provided: Yes No
Education
Activity Modification
Exercise Therapy
Manipulation and/or Mobilization
Massage
Electro / Thermal modalities
Immobilization through bracing
Health Professional’s Signature Date (dd/mmm/yyyy)
2339A2
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Musculoskeletal Program of Care (MSK POC) Care &

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Completed 11 February 2021

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