WC196 gives physical and occupational therapists a structured progress note for Colorado workers' compensation patients. It records reported improvement and ability to do job duties, attendance and effort, range of motion and manual muscle testing against the initial evaluation, a functional outcome score, up to four measurable functional goals with percent achieved, an assessment and the plan.
The treating physical or occupational therapist completes and signs it; the patient's input is recorded in the subjective section.
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Rehabilitation Communication Form
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The physical therapist or occupational therapist providing the rehabilitation; the signature line reads PT or OT Signature. The form then goes to the authorized treating physician and the insurer so they can follow progress against the plan of care.
Objective range of motion in degrees and manual muscle test grades out of 5, side by side with the initial evaluation measurements. It also tracks reported percent improvement, better or worse ability to perform listed job duties, and progress toward each functional goal.
Up to four goals the patient and therapist agree on, each specific, functional, measurable and time-framed, with the percent achieved. The therapist also explains which outcome measure is being used to follow functional progress.