Occupational Therapy Services

Discharge Report

Discharge report due within 3 business days Date of service (discharge date)(yyyy-mm-dd) Date of Report (yyyy-mm-dd)
of discharge date.            

Report type (check one only)

OT – Physical Injury (OT-PI) OT – Mental Health (OT-MH) OT – Brain Injury (OT-BI)

Worker’s information
Worker’s last name First name Middle initial WorkSafeBC claim number

                       

Date of initial referral (yyyy-mm-dd) Claim accepted for Claim not accepted for

                 

Current status
Subjective reports

     
Objective findings (updates re: objective findings outlined in the last report)

     
Basic activities of daily living — functional status (updates re: previously identified issues; interventions; etc.)

     
Instrumental activities of daily living — functional status (updates re: previously identified issues; interventions; etc.)

     
Vocational status (updates re: return-to-work status)

     
Home environment/equipment (updates re: previously identified issues; interventions; etc. If continued equipment rental is still necessary past OT
Services discharge date, indicate the reason and follow-up plan.)

     
Other

     
Analysis (Include a comprehensive analysis and clearly describe the top three barriers to return to work, if relevant)

     

Occupational therapy plan and goals

Provide an update regarding the status of short-term and long-term goals. If goals have not been met, indicate the reason and provide
discharge recommendations. Please distinguish between and document compensable and non-compensable goals and
recommendations. The provider should communicate the enclosed information to the WorkSafeBC officer prior to
submitting this report.

     
Indicate the total number of sessions the Worker has
History of Services Provided participated in from the initiation of services to discharge

OT Visit - Treatment      

Rehabilitation Worker Visit      

OT RTW Support (used in lieu of OT Visit – Treatment for all in-person
services provided to an Injured Worker who is on a GRTW)
     

Other (e.g. Telehealth)            

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 Occupational Therapy Services
Discharge Report

Worker’s last name First name Middle initial WorkSafeBC claim number

Provider’s information
Occupational therapist’s name Occupational therapist’s email address (optional)

           
Company name Payee number Company’s phone number Company’s fax number
(include area code) (include area code)
           
           
Mailing address City Province Postal code

                       

I declare that the above information is true and accurate to the best of my knowledge.
Signature Date (yyyy-mm-dd)

     

Claims Call Centre Fax Mail

Phone 604.231.8888 604.233.9777 WorkSafeBC
Toll-free 1.888.967.5377 Toll-free 1.888.922.8807 PO Box 4700 Stn Terminal
M–F, 8 a.m. to 6 p.m. Vancouver BC V6B 1J1
WorkSafeBC collects information on this form for the purposes of administering and enforcing the Workers Compensation Act. That Act, along with the
Freedom of Information and Protection of Privacy Act, constitutes the authority to collect such information. To learn more about the collection of personal
information, contact WorkSafeBC’s FIPP Office, at PO Box 2310 Stn Terminal, Vancouver BC, V6B 3W5, or email FIPP@worksafebc.com, or call
604.279.8171.

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