Sample Reports
Unsuccessful Closure Report
SLF Training
Closure Report (No RTW initiated) From:
(Add your name and title) Arete Human Resources Suite 210, 8180 Macleod Trail S Calgary, AB, T1H 2B8 Telephone: 1-888-255-5196 ext Fax: 1-403-252-6161
AUTOPOPULATED CLAIMANT Mr John Doe CONTROL # 12345-00678-00 ADDRESS 1001 Nowhere St. D.O.D. December 10, 2012 EMPLOYER Canada Post
D.O.B. POLICY # PHONE C.O.D. ACM
DIAGNOSIS
depressive episode
OCCUPATION
DATE of FINAL SESSION REPORT DATE
February 27, 2013
REFERRAL DATE
February 12, 2013
May 12, 2013
Number of sessions until closure report:
10
Arete Client Code: 12345
March 2, 1960 12345 987-654-3210 March 10, 2015 Ms Smith phone 123-456-7890 letter carrier
Professional ID: abcd
Therapists Estimate of RTW start date (M/D/Y) (if changed since progress report, please provide explanation)
July 2013, for explanation see below
Therapists Estimate of Client’s probability of successful RTW (%): ( if changed since progress report, please provide explanation)
80% Despite two sessions at work to solve conflict, it is still not solved; a third meeting is scheduled to take place May 25, 2013. Client also sprained his ankle, is currently not able to stand or walk and is seeing a physiotherapist.
388 Roncesvalles Ave, Suite 200 Toronto, ON M6R 2M9 T 866.226.9262 F 416.588.9235 www.banyanconsultants.com
Page |2
Resolved Barriers since Initial and Progress report Barrier mentioned in initial report
Comments/Explanation (if needed)
1) poor daily rhythm
client is able to get up at 8 am every day and eat three meals per day and go to bed at 10 pm, client has a regular daily rhythm with work, walks and household chores
2) poor self-care
client gets dressed every day and takes a shower every day
3) poor physical stamina
client is consistent in following the exercise program and has improved physical stamina
Ongoing Barriers to RTW (defined by therapist and discussed with client) Summary of current ongoing barriers (may include symptoms, life circumstance, workplace issues, addiction history or any other influencing factors) 1) work conflict still existing barrier
Impact Severity (1)Mild (2)Moderate (3)Severe & Serious
Observations of impact on RTW/ Solutions
Current treatment plan
moderate
third meeting is scheduled on May 25, 2013
2) client sprained ankle new barrier
moderate
despite two sessions at work to solve conflict, it is still not solved client is currently not able to walk or stand
client is seeing a physiotherapist
Which homework tools have you utilized with client?
Stress Inventory
Yes
Worrying assignment
Yes
Time management
No
388 Roncesvalles Ave, Suite 200 Toronto, ON M6R 2M9 T 866.226.9262 F 416.588.9235 www.banyanconsultants.com
Page |3
Rationale tool
Yes
Writing/Journaling assignment
Yes
Anti-depressant skills
Handouts Managing Anger, Managing Worry, Relationship building, Relaxation Skills
Other
If you have not used home work tools, please provide explanation and suggestions
No Yes managing worry and relationship building if Yes, which handout Please List: thought records
Which other tools have you used in preparing client for RTW and increasing RTW self efficacy? Roleplay
Overall Evaluation of Treatment: Client’s Progress in Resolving barriers to RTW: (provide explanation/suggestions for improvement) None Low Moderate Good Very Good 0__________________________x______5________________________________10 Evaluation/suggestions: client is having physiotherapy and a new meeting to solve conflict is scheduled Client’s Level of Engagement in Resolving barriers to RTW: (please provide evaluation) None Low Moderate Good Very Good 0_________________________________5_________x______________________10 Evaluation/suggestions: client is actively participating Client’s progress with self efficacy efforts: (please provide evaluation and suggestions for improvement) None
Low
Moderate
Good
Very Good
0_________________________x_______5________________________________10 Evaluation/suggestions: after unsuccessful meetings to solve work conflict client felt less confident in RTW but client experienced that he is able to deal with unhelpful thinking Third meeting needs to take place, is scheduled May 25, 2013.
388 Roncesvalles Ave, Suite 200 Toronto, ON M6R 2M9 T 866.226.9262 F 416.588.9235 www.banyanconsultants.com
Page |4 Rate the progress in increasing client’s overall functioning thus far: (please provide evaluation) None
Low
Moderate
Good
Very Good
0________________________x________5________________________________10 Evaluation/suggestions: Client initially made good progress when it appeared that the conflict was solved, when it became clear that further meetings were needed, client experienced a setback in unhelpful thinking. Client also sprained his ankle and is currently not able to walk or stand or participate in the exercise program. Has client worked with the online diary? (Please provide evaluation) Not at all
Sometimes
Daily
0__________________________________5_______________________x_______10 Evaluation/suggestions: none Has client participated in the individual exercise program or increased physical activity otherwise? (Please provide evaluation) Not at all
Sometimes
Daily
0__________________________________5______________________x________10 Evaluation/suggestions: client is currently not participating in exercise program but has been very active prior to sprained ankle
Overall Treatment Conclusion and summary analysis key factors contributing to unsuccessful RTW outcome: Client is currently not able to start a GRTW for the following reasons. Client needs to recover from the sprained ankle; client is currently not able to work on physical stamina and is attending sessions with the physiotherapist. Work conflict also still needs to be solved. A third meeting is scheduled for May 25, 2013. Client has learned tools to be able to assist him with having a successful RTW. Client needs to continue to work with thought records and worry assignment. Client is still not able to get up at 6 am but is improving. Client has been actively participating in the program, filled out the online diary and participated in the exercise program. It is expected that a successful RTW can start in July 2013.
Specific Input for RTW Coordinator or Case Manager: (elements that need to be addressed/considered) Client needs to be provided with time to recover from sprained ankle. Client might need assistance if the third meeting to solve the conflict is also not successful. Client can start RTW in July 2013 if conflict is solved and recovered from sprained ankle
388 Roncesvalles Ave, Suite 200 Toronto, ON M6R 2M9 T 866.226.9262 F 416.588.9235 www.banyanconsultants.com