Virginia's Workers' Compensation Commission uses this one-page diagram to set permanent partial disability benefits after amputation of fingers, metacarpals, toes or metatarsals. The treating physician draws a straight line at the exact point of amputation on the hand or foot chart and certifies personally examining and treating the patient. It often accompanies the Attending Physician's Report (Form 6).
The treating physician completes the whole chart: claim numbers, patient and employer, injury and amputation dates, which hand or foot, the line marking and the signed certification of personal examination and treatment.
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Amputation Chart
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No. The Commission's instructions say circles are not acceptable. Draw a straight line across the finger, toe, metacarpal or metatarsal at the exact level of amputation, and indicate which hand or foot is involved, so the Commission can rate the permanent partial loss accurately.
It can be, but the Commission's instructions for the Attending Physician's Report (Form 6) say that in hand or foot amputation cases the treating physician completes Form 6 and may also fill out the Amputation Chart, so the two are often filed together through WebFile.