ACC266 Psychological services action plan

**ACC266** **Psychological Services Action Plan** "This form is completed by the provider with details of the psychological services to be provided." (All checkbox options throughout this form must always appear in the output. Never omit any checkbox options. If a checkbox option is not explicitly mentioned in the transcript, contextual notes, or clinical note, leave it as '[ ]'. Do not remove or hide any checkbox options under any circumstances.) **Provider Details** 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) Signature: Address (fax number/email): [provider's address, fax number and/or email] (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 action plan: [date of action plan] (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) **Claimant Details** Claimant's name: [claimant'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) Phone number: [claimant'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) Claim number: [claimant'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 birth: [claimant's date of birth] (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) Date of injury: [claimant'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) **Case Manager Details** Case Manager name: [case manager'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) Branch: [case manager's branch] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) **Psychological Service Details** **Assessment findings confirmed?** (Mark with '[x]' based on information explicitly mentioned in the transcript, contextual notes, or clinical note. Only one of the following options must be marked with '[x]'. Do not mark more than one. Do not omit any options.) [ ] Yes (Mark with '[x]' if the assessment findings are confirmed. Leave '[ ]' if not explicitly mentioned. These 2 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.) [ ] No (Mark with '[x]' if the assessment findings are not confirmed. Leave '[ ]' if not explicitly mentioned. These 2 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.) _"Note: Case Manager approval needs to be obtained before the provision of further psychological consultations"_ If no, please provide reasons: [reasons why the assessment findings are not confirmed] (Only include if the assessment findings confirmed question above is marked '[x]' for No. If marked '[x]' for Yes, omit this placeholder but retain the heading and leave blank. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) Findings not previously recorded in assessment: [findings not previously recorded in the assessment] (Only include if the assessment findings confirmed question above is marked '[x]' for No. If marked '[x]' for Yes, omit this placeholder but retain the heading and leave blank. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) **Number of sessions required (max 10):** [number of sessions required] (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 to be completed:** [date sessions are to be completed by] (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) **Specific outcome to be achieved:** [specific outcome to be achieved through the psychological services] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) **Functional objectives to be achieved:** [functional objectives to be achieved] (Format each functional objective as a new row in a three-column markdown table. The columns are: Functional objective, Date to be achieved, and How objective will be measured. Print all dates in DD/MM/YYYY format. Use a hyphen "-" for any fields that are not mentioned. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) **Cognitive Behavioural Therapy to be provided:** (Mark with '[x]' based on information explicitly mentioned in the transcript, contextual notes, or clinical note. You may mark more than one of the following options. Do not omit any options.) [ ] Relaxation training (Mark with '[x]' if relaxation training is to be provided. Leave '[ ]' if not explicitly mentioned. Do not omit any options.) [ ] Assertiveness training (Mark with '[x]' if assertiveness training is to be provided. Leave '[ ]' if not explicitly mentioned. Do not omit any options.) [ ] Stress management (Mark with '[x]' if stress management is to be provided. Leave '[ ]' if not explicitly mentioned. Do not omit any options.) [ ] Anger management (Mark with '[x]' if anger management is to be provided. Leave '[ ]' if not explicitly mentioned. Do not omit any options.) [ ] Problem solving training (Mark with '[x]' if problem solving training is to be provided. Leave '[ ]' if not explicitly mentioned. Do not omit any options.) [ ] Social skills training (Mark with '[x]' if social skills training is to be provided. Leave '[ ]' if not explicitly mentioned. Do not omit any options.) [ ] Coping strategies (Mark with '[x]' if coping strategies are to be provided. Leave '[ ]' if not explicitly mentioned. Do not omit any options.) [ ] Goal setting (Mark with '[x]' if goal setting is to be provided. Leave '[ ]' if not explicitly mentioned. Do not omit any options.) [ ] Pain management (Mark with '[x]' if pain management is to be provided. Leave '[ ]' if not explicitly mentioned. Do not omit any options.) [ ] Other: [other CBT intervention to be provided] (Mark with '[x]' if another CBT intervention not listed above is to be provided. Leave '[ ]' if not explicitly mentioned. Do not omit any options. Only include placeholder if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder and leave blank) **General Comments:** [general comments regarding the psychological services action plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) **Claimant Signature** Claimant signature: Date: [date of claimant 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) **Case Manager Approval** _"Only required if plan differs from assessment findings or IRP"_ Case Manager signature: Date: [date of case manager approval] (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) "The information collected on this form will only be used to fulfil the requirements of the Accident Compensation Act 2001. In the collection, use and storage of information, ACC will at all times comply with the obligations of the Privacy Act 1993 and the Health Information Privacy Code 1994." **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.)