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How to use the Physiotherapy Management
Plan form
This plan must be completed in full and submitted to
the Agent by the 5th consultation. A subsequent plan is
only to be submitted on request by the injured worker’s
Employer, WorkSafe Authorised Agent or Self Insurer
to notify them of the proposed management plan.
The Clinical Framework for the Delivery of Health
Services can be found on the WorkSafe website:
www.worksafe.vic.gov.au.
Injury details
Provide an anatomical diagnosis where possible, such
as (L) rotator cu tear rather than one that is based on
symptoms, such as (L) shoulder pain.
Work status
Alternative/Modied duties: the worker is working at a
limited capacity, which may involve doing the same job in
a dierent way or completing dierent duties/jobs
Not working: the worker has either no capacity to work and
is unt for any duties, or suitable duities are not available.
Assessment
The serial use of relevant Standardised Outcome
Measures will provide you, the worker, the employer,
other healthcare professionals, WorkSafe and its
Agents information to establish progress over time.
Determining whether the worker is improving,
worsening or not changing over time can assist in
guiding future management.
Standardised Outcome Measures are preferred as they
are reliable, valid and sensitive to change. If a
Standardised Outcome Measure is not available for the
condition being seen or the goals being set, consider
using the Patient Specic Functional Scale.
Please specify the Standardised Outcome Measure
used, indicating the initial and review scores with the
respective dates.
Some frequently used standardised outcome
measures are available form the WorkSafe website
www.worksafe.vic.gov.au.
Refer to Principle 1, “Measure and demonstrate the
eectiveness of treatment” in the “Clinical Framework”
for further information.
Refer to Principle 2, “Adopt a biopsychosocial approach”
in the “Clinical Framework” for further information to
assist you in completing the Risk Measures.
For example:
Outcome
measure
Initial score Subsequent score
Neck
Disability
Index
Date
25/5/2019
Score
56%
Date
26/7/2019
Score
24%
Upper
Extremity
Functional
Index
Date
25/5/2019
Score
20/80
Date
26/7/2019
Score
64/80
Barriers
Please indicate any physical, psychological, or social
factors that may be barriers to recovery or to an early,
safe and durable return to work. Early identication and
management of these barriers can assist in optimising
outcomes and reduce the risk of long term disability.
Refer to Principle 2, “Adopt a biopsychosocial approach”
in the “Clinical Framework” for further information.
Current activity/functional goals
Goals must be related to function and return to work.
The goals should be Specic, Measureable, Achievable,
Relevant and Timed (SMART) and should be developed
in collaboration with the worker.
Principle 4, “Implement goals focused on optimising
function, participation and return to work” in the “Clinical
Framework” for further information.
For example:
Current activity/
functional limitation
SMART goals Estimated date of
achievement
Unable to walk
100m
Walk tolerance to
increase to 500m
1/6/2019
Not working Return to work for 2
days, undertaking
modied duties
10/6/2019
Proposed treatment plan and methods:
Please ensure you indicate the number of services and
duration for the treatment plan, as well as the date when
you anticipate the worker will be discharged from your
care.
If you require restricted or extended consultations you
must apply to the Worker’s Agent for prior approval.
Refer to Restricted Consultation application form on the
WorkSafe website for further information.
Please ensure you indicate the treatment methods that
you will be using to achieve the workers goals. Refer to
Principle 5, “Base treatment on the best available
research evidence” in the “Clinical Framework” for
further information
