ACC7983 Stay at Work completion report

**ACC7983** **Stay at Work – Completion Report** "A Stay at Work (SAW) provider completes and submits this form to ACC on the date the client is discharged from the SAW programme." "Submit this form to the ACC contact person or claims@acc.co.nz" **1. Client details** **Client name:** [client's full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) **Claim number:** [client's ACC claim number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) **Date of injury:** [client's date of injury] (Print the date in DD/MM/YYYY format. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) **2. Supplier Contact details** **Supplier company name:** [supplier company name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) **Service Delivery Company name:** [service delivery company name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) **Lead Provider name:** [lead provider's full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) **Lead Provider email address:** [lead provider's email address] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) **Lead Provider discipline:** [lead provider's clinical discipline] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) **Lead Provider phone:** [lead provider's phone number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) **3. Completion report** [completion report results] (Format as a four-column markdown table. The columns are: Result, Expected result achieved, Hrs per week, and Completion date. There are three result rows: "Same job, same employer", "Modified job, same employer", and "New job, same employer". For the Expected result achieved column, print "[ ] Yes [ ] No" for each row and mark '[x]' for Yes if the expected result was achieved, or '[x]' for No if not achieved, based on what is explicitly mentioned in the transcript, contextual notes or clinical note. For the Hrs per week column, print the number of hours per week. The fourth column heading is "Completion date - please note if achieved or expected". For this column, print the date in DD/MM/YYYY format followed by "[ ] Achieved [ ] Expected" and mark '[x]' for Achieved if the date is an achieved completion date, or '[x]' for Expected if the date is an expected completion date. Use a hyphen "-" for any cell where no information is available. All three rows must always appear in the output, even if not all are discussed. Only populate cell values if explicitly mentioned in transcript, contextual notes or clinical note; else leave cells with a hyphen "-".) **Has the client received medical clearance to return to work?** _"Please attach a copy of the medical clearance certification"_ [ ] Yes [ ] No (Mark with '[x]' for Yes if the client has received medical clearance to return to work. Mark with '[x]' for No if the client has not received medical clearance. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else leave both as '[ ]'.) **If the client has not returned to their pre-injury work tasks, what are the reasons?** [reasons the client has not returned to pre-injury work tasks] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) **Does this client need any more assistance from ACC?** [ ] Yes [ ] No (Mark with '[x]' for Yes if the client needs more assistance from ACC. Mark with '[x]' for No if the client does not need more assistance. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else leave both as '[ ]'.) **If yes, what help is required?** [description of further help required from ACC] (Only include if Does this client need any more assistance from ACC is marked '[x]' for Yes. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) [activities completed to support vocational rehabilitation] (Format as a two-column markdown table with the headings "Please list all activities completed to support vocational rehabilitation" and "Date completed". Each row represents one activity. Print dates in DD/MM/YYYY format. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit this table, retain the section heading, and leave blank.) **4. Provider declaration and signature** "I declare the information provided by me on this form is, to the best of my knowledge, accurate and complete." Provider name: [provider's full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) Provider discipline: [provider's clinical discipline] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) Signature: Date: [date of signature] (Print the date in DD/MM/YYYY format. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) "When we collect, use and store information, we comply with the Privacy Act 2020 and the Health Information Privacy Code 2020. For further details see ACC's privacy policy, available at www.acc.co.nz. We use the information collected on this form to fulfil the requirements of the Accident Compensation Act 2001." **Items for Clinician Review** [checklist of items requiring clinician verification before finalising] (Print each flagged item on its own line beginning with '-' (bullet point), followed by the section name and a brief description of what the clinician needs to verify. Flag any content where review is warranted before sign-off. Examples of what to flag include: identity and demographic details that were unclear, partial, or potentially misheard, such as patient name spelling, NHI number, ACC claim number, date of birth, contact details, or address; dates that were spoken partially or ambiguously, such as "the third of the third" without a year, "last Tuesday" without an explicit date, date of injury, date of first treatment, date of assessment, or follow-up review date; mechanism of injury described vaguely or incompletely, such as "twisted awkwardly" without direction or load, "fell" without specifying surface or height, or a mechanism inferred from outcome rather than stated; diagnoses lacking specificity, such as body region without side, "shoulder pain" without specifying which shoulder, a general diagnosis without laterality, chronicity, or grade, or a working diagnosis where a definitive one is expected; numerical values that were partial, unclear, or potentially misheard, such as pain scores, range of motion in degrees, strength grades, blood pressure readings, medication doses, dosing frequencies, sessions per week, hours per day, percentage ratings, or impairment ratings; codes or classifications mentioned but not clearly stated, such as Read codes, ICD codes, work capacity percentages, whole-person impairment ratings, or ACC-specific category codes; provider details that were not fully stated, such as referring practitioner name and provider number, signing clinician designation, ACC provider ID, or supplier ID; functional capacity or independence ratings where the spoken value was indistinct, where multiple ratings were given without clarifying which was final, or where a rating was implied but not explicitly stated; return-to-work plan elements partially captured, such as target return date, hours per day, days per week, modified duties, lifting or postural restrictions, graduated return phases, or review date; treatment plan details with potential ambiguity, such as medication name, dose, frequency, route, or duration; therapy modality, session count, frequency, or review point; equipment or aid prescriptions without size, model, or supplier; clinical content inferred from context rather than explicitly stated, such as an assumed diagnosis based on described symptoms, an inferred mechanism, an inferred prior medical or surgical history, or an inferred medication based on a condition; conflicting or contradictory information across the transcript, contextual notes or clinical note, such as different dates of injury given at different points, conflicting body regions, conflicting laterality, or conflicting medication details; sections of the ACC form where expected information was not mentioned at all, such as consent confirmation, declaration date, clinician signature, mandatory demographic fields, or required outcome ratings; abbreviations, acronyms, or shorthand terms used by the clinician that may have multiple meanings or were not clearly resolved during the consultation; and any quoted values where the audio was likely affected by background noise, simultaneous speech, or the patient and clinician disagreeing on a detail. For each flagged item, name the section of the form it belongs to and describe the issue in one short sentence. If no items require review based on the transcript, contextual notes or clinical note, print "None flagged." beneath the section heading. Always include this section heading.) (Always retain all section and sub-section headings in the output, regardless of whether content is available to populate them. If no information is explicitly mentioned for a given section or sub-section, leave the area beneath the heading blank but never remove the heading itself.)