PRE-AUTHORIZATION REQUEST FORM
Please indicate your request type with an X:
[ ] First rehabilitation report
[ ] Extension of treatment period required
[ ] Clinical vocational rehabilitation intervention
[ ] Amendment to treatment codes required
[X] Additional treatment sessions are required
INJURY / SYMPTOM DETAILS
Diagnosis: Right wrist distal radius fracture, post-operative
ICD 10 Codes: S52.501A
Date of injury: 15 August 2024
Date of surgery: 22 August 2024
Weeks post: 10 weeks post-surgery
F/U Dr: "Dr. Thomas Kelly"
RTW: Modified duties, light lifting only, 4 hours/day
CURRENT PRESENTATION
Impairment Description
Objective report:
Patient reports persistent moderate pain (4/10 at rest, 6/10 with activity) in the right wrist, particularly during gripping and fine motor tasks. She struggles with everyday activities such as dressing, cooking, and opening jars. Her ability to type and use a computer mouse for extended periods is limited, impacting her modified work duties. She expresses frustration with the slow progress and a strong desire to regain full function for independent living and return to full-time work.
Outcome Measures
Range of movement (Active):
- Wrist Flexion: R 30° / L WNL
- Wrist Extension: R 35° / L WNL
- Ulnar Deviation: R 10° / L WNL
- Radial Deviation: R 5° / L WNL
- Forearm Supination: R 60° / L WNL
- Forearm Pronation: R 70° / L WNL
- Digits: Full AROM bilateral except for limited thumb opposition and flexion of D2-D5 on the right hand.
Grip strength:
- R: 12 kg (average) / L: 35 kg (average)
Pinch strength:
- R: Tip pinch 1.5 kg, Lateral pinch 2.0 kg, Palmar pinch 2.5 kg (average)
Swelling: Mild oedema noted dorsally over the right wrist, circumference 19cm (Left 17.5cm).
Sensation: Intact to light touch and sharp/dull discrimination in all dermatomes of the right hand.
Scar: Well-healed surgical incision on the volar aspect of the right wrist, slightly raised and hyperpigmented but non-tender.
Wound: Closed and dry.
Pain: Rates pain as 6/10 with functional use, sharp and aching in nature, exacerbated by gripping and sustained wrist movements.
Treatment Provided
- Manual therapy techniques for scar mobilisation and joint mobilisation of the wrist.
- Therapeutic exercises focusing on gentle active range of motion for wrist and digits, light grip strengthening with putty, and pain-free wrist extension exercises.
- Education on pain management strategies, activity modification for ADLs, and ergonomic principles for computer use.
- Home exercise programme instructed to include tendon gliding, wrist mobilisations, and progressive light resistance exercises.
Plan
The patient requires an additional 6 weeks of occupational therapy to address persistent functional limitations, improve strength, and facilitate a full return to work. The plan includes advanced strengthening, fine motor coordination training, and simulated work tasks.
A. TREATMENT PLAN
Rehabilitation Goals
[X] Improve AROM of the affected hand for successful participation in activities.
[X] Improve strength of the affected hand for successful participation in activities.
[X] Promote oedema management so that AROM is not impaired for activity participation.
[X] Promote scar management to prevent excess scar tissue formation or adhesions which may limit AROM for activity participation.
[X] Facilitate desensitisation to manage pain during activity participation.
[ ] Provide splinting to rest the hand and facilitate healing of the hand.
[X] To comment on the client's functional abilities (injury specific) compared to their related job demands.
[ ] Facilitate improvement in physical endurance and strength by means of work hardening to enable the patient to cope with the demand required of an 8-hour work day.
[X] Facilitate independent and pain-free successful participation in ADL and RTW.
[ ] Other:
Anticipated Duration and Frequency of Treatment
Overall expected number of treatment sessions: 12
Frequency of treatment intervention: 2 sessions per week for 6 weeks
Complicating Factors:
The patient's job as an administrative assistant requires extensive computer use and fine motor dexterity, which currently exceeds her functional capacity. She also lives alone, which makes managing household tasks challenging without full bilateral hand function.
PRE-AUTHORIZATION REQUEST FORM
(Always include this section.)
Please indicate your request type with an X:
[ ] [Mark with X if this is the first rehabilitation report](Mark with "[X]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, else leave "[ ]" for information not explicitly mentioned. Do not omit any checkboxes, even if nothing is reported.) "First rehabilitation report"
[ ] [Mark with X if an extension of treatment period is required](Mark with "[X]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, else leave "[ ]" for information not explicitly mentioned. Do not omit any checkboxes, even if nothing is reported.) "Extension of treatment period required"
[ ] [Mark with X if a clinical vocational rehabilitation intervention is required](Mark with "[X]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, else leave "[ ]" for information not explicitly mentioned. Do not omit any checkboxes, even if nothing is reported.) "Clinical vocational rehabilitation intervention"
[ ] [Mark with X if an amendment to treatment codes is required](Mark with "[X]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, else leave "[ ]" for information not explicitly mentioned. Do not omit any checkboxes, even if nothing is reported.) "Amendment to treatment codes required"
[ ] [Mark with X if additional treatment sessions are required](Mark with "[X]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, else leave "[ ]" for information not explicitly mentioned. Do not omit any checkboxes, even if nothing is reported.) "Additional treatment sessions required"
INJURY / SYMPTOM DETAILS
Diagnosis: [Patient's diagnosis](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading. Do not invent or infer a diagnosis.)
ICD 10 Codes: [ICD-10 codes relevant to the diagnosis](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading.)
Date of injury: [Date of injury](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading.)
Date of surgery: [Date of surgery](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading.)
Weeks post: [Weeks post-injury or post-surgery](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading.)
F/U Dr: [Follow-up doctor or specialist](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading.)
RTW: [Return to work status](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading.)
CURRENT PRESENTATION
<u>Impairment Description</u>
Objective report:
[Patient's subjective report of pain, symptoms, and functional status regarding ADLs and IADLs](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading. Write in paragraphs of full sentences.)
<u>Outcome Measures</u>
(Only include if there are any outcome measures mentioned in the transcript, contextual notes, or clinical note, else omit this entire section including the heading.)
Range of movement (Active):
[Summary of wrist and forearm range of motion](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely. List as bullet points, for example '- Wrist Flexion: R [value] / L [value]'. For normal or unaffected sides, state 'WNL'.)
[Summary of digit range of motion](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely. List as a bullet point, providing a summary statement like '- Digits: Full AROM bilateral except for [specific deficit]'.)
Grip strength:
[Summary of grip strength](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this section completely. List as bullet points, for example '- R: [value] kg (average)'. If not tested, state 'Not formally tested'.)
Pinch strength:
[Summary of pinch strength](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this section completely. List as bullet points, for example '- R: [value] kg (average)'. If not tested, state 'Not formally tested'.)
Swelling: [Swelling description or measurement](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.)
Sensation: [Sensation description or test results](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.)
Scar: [Description of scar quality](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.)
Wound: [Description of wound status](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.)
Pain: [Description of pain with functional use and rating](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.)
<u>Treatment Provided</u>
[Summary of treatments provided during the session and home exercise programme instructions](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this section completely. List as bullet points.)
<u>Plan</u>
[Summary of the treatment plan and next steps](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this section completely.)
A. TREATMENT PLAN
<u>Rehabilitation Goals</u>
[ ] [Mark with X if improving AROM of the affected hand is a current goal](Mark with "[X]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, else leave "[ ]" for information not explicitly mentioned. Do not omit any checkboxes, even if nothing is reported.) "Improve AROM of the affected hand for successful participation in activities."
[ ] [Mark with X if improving strength of the affected hand is a current goal](Mark with "[X]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, else leave "[ ]" for information not explicitly mentioned. Do not omit any checkboxes, even if nothing is reported.) "Improve strength of the affected hand for successful participation in activities."
[ ] [Mark with X if oedema management is a current goal](Mark with "[X]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, else leave "[ ]" for information not explicitly mentioned. Do not omit any checkboxes, even if nothing is reported.) "Promote oedema management so that AROM is not impaired for activity participation."
[ ] [Mark with X if scar management is a current goal](Mark with "[X]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, else leave "[ ]" for information not explicitly mentioned. Do not omit any checkboxes, even if nothing is reported.) "Promote scar management to prevent excess scar tissue formation or adhesions which may limit AROM for activity participation."
[ ] [Mark with X if desensitisation to manage pain during activity participation is a current goal](Mark with "[X]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, else leave "[ ]" for information not explicitly mentioned. Do not omit any checkboxes, even if nothing is reported.) "Facilitate desensitisation to manage pain during activity participation."
[ ] [Mark with X if splinting to rest the hand and facilitate healing is a current goal](Mark with "[X]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, else leave "[ ]" for information not explicitly mentioned. Do not omit any checkboxes, even if nothing is reported.) "Provide splinting to rest the hand and facilitate healing of the hand."
[ ] [Mark with X if commenting on the client's functional abilities compared to job demands is a current goal](Mark with "[X]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, else leave "[ ]" for information not explicitly mentioned. Do not omit any checkboxes, even if nothing is reported.) "To comment on the client's functional abilities (injury specific) compared to their related job demands."
[ ] [Mark with X if work hardening to improve physical endurance and strength is a current goal](Mark with "[X]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, else leave "[ ]" for information not explicitly mentioned. Do not omit any checkboxes, even if nothing is reported.) "Facilitate improvement in physical endurance and strength by means of work hardening to enable the patient to cope with the demand required of an 8-hour work day."
[ ] [Mark with X if facilitating independent and pain-free participation in ADL and RTW is a current goal](Mark with "[X]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, else leave "[ ]" for information not explicitly mentioned. Do not omit any checkboxes, even if nothing is reported.) "Facilitate independent and pain-free successful participation in ADL and RTW."
[ ] [Mark with X if there are other goals not listed above](Mark with "[X]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, else leave "[ ]" for information not explicitly mentioned. Do not omit any checkboxes, even if nothing is reported.) "Other: [Any additional rehabilitation goals not captured above](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading.)"
<u>Anticipated Duration and Frequency of Treatment</u>
Overall expected number of treatment sessions: [Total number of expected treatment sessions](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading.)
Frequency of treatment intervention: [Frequency and duration of treatment, including sessions per week and total number of weeks](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading.)
<u>Complicating Factors:</u>
[Complicating factors including job demands or other barriers to recovery](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading.)
