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3.8.1 The Rehabilitation Assessment Report
After receiving the rehabilitation referral, the rehabilitation service provider is required to make contact with the client to undertake an initial rehabilitation assessment. This process may involve one or a series of appointments or consultations depending on the complexity of the case.
Information gathered from the consultations and assessments is compiled and forms the basis of the Rehabilitation Assessment Report and the Rehabilitation Plan. Refer to section 3.8.2 for further information about the Rehabilitation Plan.
The Rehabilitation Assessment Report (DVA form D1334) can be accessed through the DVA forms portal.
The Rehabilitation Assessment Report will:
- determine the client's capacity to undertake rehabilitation and appropriate related activities;
- determine whether the rehabilitation provider will need to make immediate phone contact with the Rehabilitation Coordinator to advise them that a client has immediate or urgent needs, or is at risk in any way, and negotiate how these needs can be addressed as quickly as possible;
- be informed by medical evidence from the client's treating medical practitioners;
- address all matters included in the standard rehabilitation documentation - where an item does not apply to the client, the report should provide brief reasons as to why the item is not relevant. The points highlighted in the comment boxes, attached to each of the items are to be used to guide the assessment process;
- identify the client's expectations, motivations and barriers to rehabilitation;
- acknowledge the general environment in which the client is living, socialising and working;
- include a comprehensive analysis of the client's medical condition(s), current treatment and possible limitations and restrictions – evidence of input from the current treating practitioner(s) is essential;
- provide a detailed review of the client's psychosocial status, including daily functioning needs and barriers to progress towards rehabilitation goals;
- identify the client's employment status;
- recommend rehabilitation interventions and actions to be taken that are Specific, Measurable, Achievable, Realistic within a given Timeframe (SMART);
- recommend medical management, psychosocial and vocational rehabilitation interventions where appropriate to ensure a whole of person approach;
- clearly state the person's rehabilitation goals;
- flag whether aids, appliances or alterations to the client's home or workplace or other assistance relevant to the client's individual needs may be required;
- include the client's name and claim number in the footer of the document; and
- include all necessary supporting documents and reports, ensuring they are signed-off by the rehabilitation service provider.
The following mandatory timelines apply:
- client contact will need to be established and the first assessment review meeting undertaken within 7 calendar days from the date of referral for a rehabilitation assessment; and
- the rehabilitation assessment must be completed within a 21 day calendar day timeframe following the referral (unless an independent assessment is required for inclusion in the final report).
Negotiation with the Rehabilitation Coordinator is required where a provider believes that these timeframes need to be extended, due to the client’s needs and circumstances. If this occurs the Rehabilitation Coordinator needs to ensure information about the discussion including, brief reasons about why the deadlines have not been met is recorded in the client case in R&C ISH. A copy of relevant correspondence should be also be uploaded as an attachment to the client’s R&C ISH case.
Detailed specific assessments such as a Functional Capacity Assessment should only be undertaken at the time of the initial rehabilitation assessment following the recommendation and approval of the Rehabilitation Coordinator.
The Rehabilitation Assessment report should be uploaded electronically by the Rehabilitation Provider to R&C via ISH. The DVA Rehabilitation Coordinator will need to send the Rehabilitation Provider an email with information about how to upload to R&C ISH and the Transaction Reference Number to be used for the individual client.