Industrial Rehabilitation Services: Reporting Requirements

Each employee will have an individualized evaluation. All documentation will be type written for ease in reading and accuracy. Protocols for treatment will be developed with each medical director per plant/medical protocol. An example of an outline of a typical evaluation and treatment is listed below.

Example of Visits and Time Allocation
Medical Visit (non-recordable), evaluation and report only – 45 minutes

First example = A hand evaluation for a possible diagnosis such as carpal tunnel syndrome:

• Subjective history is taken, past medical history, medications, previous injury, time on job etc.
• Job station is identified and explored for risk factors
• Objective data gathering
• Sensation testing: Semmes Weinstein Monofilament testing and 2-point discrimination
• Strength testing: Grip strength, pinch strength, specific manual muscle testing
• Range of motion measurements: Wrist and digits
• Edema measurements: Volumetric and/or girth measurements
• Documentation of all the above with a clinical impression provided
• All data is discussed with medical director and nursing staff to assist in development of a comprehensive treatment plan
• Medical cases then receive detailed home exercises program handouts and individualized instructions to ensure understanding
• Instruction of home exercise program: appropriate stretching and/or strengthening exercises to address identified problems such as flexibility, strength, edema reduction
• Follow up as needed for any additional instructions or care
• Specific testing is recommended such as EMG for further diagnostic as needed
• Follow up job site analysis as needed to work station

Therapy treatment session for patient with carpal tunnel syndrome (post-surgical) - 45 min to 1 hour consisting of all the above plus the following:

• Custom splint fabrication with thermoplastics for involved hand\
• Patient education regarding wear, care, application and rationale of splint
• Performance of therapeutic exercise in clinic for ROM, strength and/or fine motor coordination
• Instruction in home exercise program
• Follow up job site analysis as needed to work station if not previously completed

Initial evaluation session for patient with rotator cuff repair (post-surgical)- 1 hour consisting of:

• Subjective history is taken, past medical history, medications, previous injury, time on job etc.
• Job station is identified and explored for risk factors
• Objective data gathering:
• Strength testing: specific manual muscle testing
• Range of motion measurements: shoulder and scapula and possibly cervical spine
• Documentation of all the above with a clinical impression provided
• Instruction of home exercise program: appropriate stretching and/or strengthening exercises to address identified problems such as flexibility, strength, edema reduction
• Treatment sessions as indicated below
• Documentation is provided for the medical department as well as the outside surgeon for initial evaluation as well as prior to all follow-up physician visits
• Follow up job site analysis as needed to work station

Treatment session for patient with rotator cuff repair (post-surgical) - 1 hour consisting of:

• Modality application: Ultrasound, heat, ice
• Manual techniques such as passive stretching and joint mobilization to increase shoulder range of motion
• Therapeutic exercise to address ROM, strength of associated shoulder musculature
• Functional activities to simulate patient’s work and re-train functional patterns
• Patient education regarding home exercise program

Walkthrough visits, in conjunction with medical, safety or other team members identified by each individual plant, 30 minutes consisting of:

• Job site analysis, such as push/pull forces and anthropometrical assessment
• Consultation with medical department, ergonomics, safety, supervisor, and/or employee
• Walkthrough write-up consisting of job description identified OSHA risk factors, suitability of job for employee, etc.