The WSIB requires this four-page report when a worker completes the mild traumatic brain injury program of care or is discharged, including when they stop attending. It records employment status at discharge, whether the person has returned to pre-injury function, outstanding symptoms, response to treatment, the Rivermead score, Patient-Specific Functional Scale scores from mid-point to discharge, and accommodations for return to work.
The registered regulated health professional delivering the program, such as a chiropractor, occupational therapist or physiotherapist, completes and signs the report.
Download the current version from the source each time; forms change without notice.
Mild traumatic brain injury program of care: Care and outcomes summary
Sommaire des soins et des résultats dans le cadre du Programme de soins pour les lésions cérébrales traumatiques légères
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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The form says you must submit it when the injured person completes the mTBI program of care or whenever they are discharged, including if they did not return or self-discharged. The fee schedule asks for it within two business days of the last treatment, and the fee is not paid if it arrives after 14 days.
The Rivermead Post-Concussion Symptoms Questionnaire total out of 64, excluding other difficulties, and the Patient-Specific Functional Scale for three to five activities, at least two work-related, comparing mid-point and discharge scores. You also rate response to treatment, from fully recovered to worsening, and say whether the person has returned to pre-injury function.
Yes. The French version is the Sommaire des soins et des résultats dans le cadre du Programme de soins pour les lésions cérébrales traumatiques légères (10393B), and the English form notes that it is available in French. Submit either version through wsib.ca/submit.