ACC6272 Pain management plan, review, update and completion report

**ACC6272** **Pain management plan, review, update and completion report** "Complete this form to let us know about this client's pain management plan, their progress and your final completion report." "You can use the following table to determine which sections to complete and indicate which report you're submitting back to us." | If you're reporting on the… | then complete… | and check the relevant box: | |-----------------------------|----------------|-----------------------------| | initial interdisciplinary team meeting and Client care plan | Parts A, B and C | [ ] (Mark with '[x]' if this report covers the initial interdisciplinary team meeting and client care plan.) | | subsequent interdisciplinary team meeting and/or care plan updates | Part C and D | [ ] (Mark with '[x]' if this report covers a subsequent interdisciplinary team meeting and/or care plan updates.) | | service completion | Part E | [ ] (Mark with '[x]' if this report covers service completion.) | "After each update, return the updated form to the ACC contact email address in Part A, Section 3. below." **Part A – Key contact details** **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) **ACC 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) **2. Vendor details** **Vendor name:** [vendor 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) **Vendor ID number:** [vendor identification 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) **Name of Key worker:** [key worker'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) **Key worker phone:** [key worker'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) **Key worker email:** [key worker'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) **3. ACC contact details** "Does the client have a Recovery Team Member?" [ ] Yes (Mark with '[x]' if the client has a Recovery Team Member. If marked, populate the Recovery Team Member, phone number, and email address fields below.) [ ] No (Mark with '[x]' if the client does not have a Recovery Team Member.) "(If yes please provide details below)" **ACC Recovery Team Member:** [ACC Recovery Team Member's name] (Only include if the client has a Recovery Team Member is marked '[x]' for Yes. If marked '[x]' for No, omit placeholder, retain section heading and lead-in, and leave blank) **ACC contact phone number:** [ACC contact 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) **ACC contact email address:** [ACC contact 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) **Part B – Initial assessment** **4. Initial interdisciplinary team meeting** "Please provide your interdisciplinary team meeting minutes, summarising your assessment of this client. Refer to the Pain Management Operational Guidelines for instructions on what to include in this section." "Please list the members of the interdisciplinary team and their profession." [interdisciplinary team meeting minutes summarising the assessment of this client] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) [members of the interdisciplinary team and their profession] (Print each team member on its own line with their profession. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) **5. Confirmation of suitability for pain management service** "Is the client under the correct Pain Management service level?" [ ] Yes (Mark with '[x]' if the client is under the correct pain management service level.) [ ] No, please indicate which service level you recommend instead: (Mark with '[x]' if the client is not under the correct pain management service level. If marked, indicate the recommended service level below and complete the explanation field.) [ ] Community Service Level One (Mark with '[x]' if the recommended service level is Community Service Level One. Only populate if the client is not under the correct pain management service level is marked '[x]' for No.) [ ] Community Service Level Two (Mark with '[x]' if the recommended service level is Community Service Level Two. Only populate if the client is not under the correct pain management service level is marked '[x]' for No.) [ ] Tertiary services (Mark with '[x]' if the recommended service level is Tertiary services. Only populate if the client is not under the correct pain management service level is marked '[x]' for No.) [ ] Group education (Mark with '[x]' if the recommended service level is Group education. Only populate if the client is not under the correct pain management service level is marked '[x]' for No.) [ ] No, the client is not suitable for Pain Management services: (Mark with '[x]' if the client is not suitable for pain management services.) Please explain why any recommended change is needed: [explanation of why a change in service level is needed or why the client is not suitable for pain management services] (Only include if the client is not under the correct pain management service level is marked '[x]' for No or the client is not suitable for pain management services is marked '[x]'; else omit placeholder, retain section heading and lead-in, and leave blank) **6. Duration of service** Recommended number of weeks: [recommended number of weeks for the service] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) Proposed start date: [proposed start date for the service] (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) Next interdisciplinary team meeting or review date: [next interdisciplinary team meeting or review date] (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) Proposed end date: [proposed end date for the service] (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) **7. Who will be involved in delivering the service?** "Please list the details of each provider that will be involved in this service." | Names of provider | Professional scope | |-------------------|--------------------| | [provider name] | [provider's professional scope] | (Populate one row per provider involved in delivering the service. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) **Part C – Client Care Plan** **8. Plan, Progress and Completion** | Describe the client's rehabilitation goal | How will this be achieved? | Who is responsible? | |------------------------------------------|----------------------------|---------------------| | [client's rehabilitation goal including functional, psychological and social goals] | [how the goal will be achieved, including treatment type and frequency] | [who is responsible for this goal, including their discipline] | (Populate one row per rehabilitation goal discussed. Include functional, psychological, and social goals. For each goal, include a goal date and revised goal date if applicable, within the first column. Print dates in DD/MM/YYYY format. For "How will this be achieved?", include the treatment type and frequency, e.g. cognitive behavioural therapy (CBT) 2/week, strengthening 3/week, pain education 1 session. For "Who is responsible?", include their discipline, e.g. occupational therapist (OT), physiotherapist (PT), psychologist, medical practitioner. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) **General Comments:** [comments about goals, progression, and achievement] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) **Part D – Service updates** **9. Subsequent interdisciplinary team meeting and/or care plan updates** "Please provide your interdisciplinary team meeting minutes; summarising your assessment of this client, providing comment about the client's progress towards achieving their goals, revised goal dates if applicable and advice if additional support is needed." [interdisciplinary team meeting minutes summarising the client's progress towards achieving their goals, revised goal dates if applicable, and advice if additional support is needed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) "Please attach a copy of the treating clinician's clinical notes eg Physiotherapy notes." **Part E – Completion report** **10. Completion report recommendations** "Complete this section when the service has been completed. If the client had a successful programme, then please summarise client outcomes and status regarding their pain below. Please include the client's comments and feedback." "If the client hasn't achieved all their goals and you have recommendations for next steps in their rehabilitation, please summarise and include any referrals to another provider or service below. We may contact you to talk about these." [completion report summarising client outcomes, status regarding their pain, client comments and feedback, and any recommendations for next steps in their rehabilitation including referrals to another provider or service] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) **11. Declaration and signature** "As the Keyworker and a member of the interdisciplinary team, I certify that I have" "- personally examined and/or treated the client" "- discussed their treatment options with them and advised why the recommended intervention(s) are appropriate in this case." "The client (or their representative) has authorised me to provide this information to ACC." **Key worker name:** [key worker'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) **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.)