ACC7984 Pain Management Services Triage Report

**ACC7984** **Pain Management Services Triage Report** "Please complete this form to let us know about this client's triage assessment, the conclusions regarding the likely diagnosis/es and cause/s and the proposed clinical care pathway." "When you've finished, please send a copy to the ACC recovery team member managing the Claim or to claims@acc.co.nz if you are unsure of the Recovery Team Member/Recovery Team." **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) Address: [client's residential address] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain 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 lead-in, and leave blank) Date of birth: [client'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 lead-in, and leave blank) **2. Vendor details** Supplier name: [supplier/practice name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain lead-in, and leave blank) Vendor number: [vendor number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain lead-in, and leave blank) Phone number: [vendor phone number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain lead-in, and leave blank) Vendor email address: [vendor email address] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain lead-in, and leave blank) **3. Confirmation of suitability for the Pain Management Service** **Recommendation:** "Note: Choose Group Programme when required, and/or one of the following Community Level 1, Community Level 2 or Tertiary if required" "Rationale for any recommended Pain Management Service is provided in the Summary of Findings in Section 4." [ ] Not suitable for a Pain Management service (see below) (Mark with '[x]' if the client is not suitable for a pain management service) [ ] Group Programme (Mark with '[x]' if the client is recommended for the Group Programme) [ ] Community Services Level 1 (Mark with '[x]' if recommended — only one of Community Level 1, Community Level 2, or Tertiary Delivery Services can be selected) [ ] Community Services Level 2 (Mark with '[x]' if recommended — only one of Community Level 1, Community Level 2, or Tertiary Delivery Services can be selected) [ ] Tertiary Delivery Services (Mark with '[x]' if recommended — only one of Community Level 1, Community Level 2, or Tertiary Delivery Services can be selected) "If the client is not suitable for the Pain Management Service, please explain why and any recommendations on what support or alternative service the client needs:" [explanation of why the client is not suitable and recommendations for alternative service or support] (Only include if Not suitable is marked '[x]'; else omit placeholder, retain lead-in, and leave blank) "For clients who are recommended for the Pain Management Service, do they meet the eligibility criteria?" [ ] Not applicable, the Pain Management Service is not recommended (Mark with '[x]' if the service is not recommended) [ ] Yes, the client meets the eligibility criteria for the recommended Pain Management Service level (Mark with '[x]' if eligibility criteria are met) [ ] No, please provide clinical rationale as to why the Client would benefit from a Pain Management service despite not meeting the eligibility requirements (Mark with '[x]' if criteria are not met but service is still warranted) [clinical rationale for recommending service despite not meeting eligibility requirements] (Only include if No is marked '[x]'; else omit placeholder, retain lead-in, and leave blank) **4. Triage report** Description of the client's history "Include information on previous persistent pain, mental health conditions, substance misuse and any underlying conditions" **Injury history** [description of the mechanism of injury, date of injury, and body region affected] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain subheading, and leave blank) **Pain history** [description of pain duration, onset pattern, quality and nature of pain, and any progression or spread over time] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain subheading, and leave blank) **Previous persistent pain** [description of any prior persistent pain episodes, relevant treatment history, and response to past interventions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain subheading, and leave blank) **Mental health history** [description of diagnosed or suspected mental health conditions, including previous episodes of depression, anxiety, PTSD, or other relevant history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain subheading, and leave blank) **Substance use** [description of current or historical use of alcohol, opioids, or other substances, using clinical and non-judgemental language] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain subheading, and leave blank) **Underlying conditions** [description of comorbidities relevant to the pain presentation, such as inflammatory conditions, sleep disorders, or features of central sensitisation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain subheading, and leave blank) **Current treatments** [description of current medications, allied health input, and GP management] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain subheading, and leave blank) **Work and functional status** [description of current employment status, work capacity, any restrictions or modified duties in place] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain subheading, and leave blank) Summary of Findings "Include an evaluation of all possible causes and contributors to the pain/s. Describe the relationship between the pain the Client is experiencing, and the ACC covered injury. Include information about the Client's cultural considerations, values, and beliefs. This section should provide rationale for the recommended Pain Management Service in Section 3 and estimated timeframes of service." [Write a flowing clinical narrative of approximately 350–500 words structured using the Te Whare Tapa Whā model. Do not use bullet points. Write in third person, using the client's first name where known. For each dimension, identify both what is going well (strengths, protective factors) and what needs attention (contributors to pain, barriers to recovery). Structure as follows: Taha Tinana — Physical Wellbeing: Open the narrative here. Describe preserved physical function and capacity alongside injury background, pain characteristics (location, quality, spread, triggers, aggravating and relieving factors), functional limitations, physical examination findings, red flag status, and medication burden. Draw the relationship between the ACC-covered injury and the current pain presentation — is it clear, complex, or multifactorial? Taha Hinengaro — Mental and Emotional Wellbeing: Transition naturally from the physical picture. Describe psychological strengths such as insight, motivation, or help-seeking behaviour, alongside challenges including mood, anxiety, cognitive patterns (catastrophising pattern from PCS, fear-avoidance beliefs), and how distress is interacting with or amplifying the pain experience. Interpret the DASS-21 findings as a picture of the person's emotional world — not a list of scores. Taha Wairua — Spiritual Wellbeing: Address meaning, purpose, identity, and hope. Describe what sustains or grounds the client — their values, sources of meaning, resilience, or motivation for recovery — alongside what has been disrupted by the injury (loss of role, identity, hopelessness, or disconnection from purpose). Include cultural or spiritual beliefs about pain and healing if known. Taha Whānau — Family and Social Wellbeing: Describe the social landscape, naming who supports the client (whānau, family, trusted relationships, workplace allies) alongside what needs attention (relationship strain, social isolation, work environment dynamics). Reflect on whether the social environment is reinforcing recovery or inadvertently maintaining avoidance or disability behaviour. Whenua — Cultural Identity and Grounding: The whenua is the foundation the wharenui stands on. Describe the client's connection to identity, culture, place, and roots. Note cultural background, iwi or hapū affiliation if known and consented, language preferences, and any cultural considerations that should shape the treatment approach. If cultural information is not yet known, state clearly that cultural safety planning is pending and should be explored at intake. Never leave this dimension entirely blank. Close with a formulation statement: what is primarily driving and maintaining the pain, the likely trajectory with and without intervention, the rationale for the recommended service level, and the estimated programme timeframe.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank) List of medicines [list of all current medications. Print each medicine on its own line. Flag any opioid medications clearly with the word OPIOID in the notes column. Note any polypharmacy concerns. If no medications are reported, state "Nil reported."] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain heading, and leave blank) | Medication | Dose | Frequency | Prescribing Clinician | Notes | |---|---|---|---|---| | [medication name] | [dose] | [frequency] | [prescriber] | [notes — flag OPIOID if applicable] | Summary of ePPOC results [Write a clinical narrative interpretation of the ePPOC outcome measures provided in the contextual notes. Do not simply restate scores — interpret what they mean for this person's function and recovery. Cover each measure: BPI: Report pain severity composite and interference composite (0–10 each). Interpret functionally — what level of limitation do these scores suggest in daily life, mobility, sleep, and work capacity? DASS-21: Report each subscale score and severity band (Normal / Mild / Moderate / Severe / Extremely Severe). Describe clinical significance — which domain is most elevated, and how is distress interacting with the pain experience? PCS: Report total score (0–52) and identify the dominant subscale (Rumination, Magnification, or Helplessness). Interpret the catastrophising pattern and its implications for programme engagement. PSEQ: Report total score (0–60). Interpret the client's confidence in managing function despite pain — active self-management or significant self-limiting behaviour? Opioid flag: If opioids are present, note this and describe clinical implications for programme participation, dependence risk, and dose trajectory.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain heading, and leave blank) Date of Triage: [date of triage assessment] (Print the date in DD/MM/YYYY format. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain lead-in, and leave blank) Date of IDT Review: [date of interdisciplinary team review] (Print the date in DD/MM/YYYY format. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain lead-in, and leave blank) | Role | Name | Discipline | |------|------|------------| | [role, e.g. Triage Clinician, IDT Member] | [name] | [discipline] | (Populate one row per clinician or IDT member involved in the triage. Include the triage clinician and all IDT members. Minimum IDT composition: psychology + medical. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder rows, retain table headers, and leave blank) **5. Declaration and signatures** "I certify that: - I have personally examined and/or treated the client. - I have discussed the recommendations I have made in this report and the rationale for these with the client and other provider/s who have performed the triage and case review. - The client (or their representative) has authorised me to provide this information to ACC." Name of Triage clinician: [triage clinician's full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain 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 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 and submitting to ACC. Print each flagged item on its own line beginning with '-' (bullet point), followed by the section name and a brief description of what needs verification. Flag anything where the clinician should check before sign-off, including: identity or demographic details that were unclear, partial, or potentially misheard (name spelling, claim number, date of birth, address); dates spoken partially or ambiguously (date of injury, triage date, IDT review date); mechanism of injury described vaguely or incompletely; diagnoses lacking specificity (no laterality, no chronicity, working diagnosis where definitive is expected); numerical values that were unclear or potentially misheard (pain scores, medication doses, ePPOC scores, ROM measurements); provider or vendor details not fully stated; opioid medications requiring prescriber confirmation; cultural considerations not yet explored or confirmed with the client; sections where expected information was not mentioned at all (consent, IDT composition, ePPOC scores); clinical content inferred from context rather than explicitly stated; conflicting information across the transcript, contextual notes, or clinical note; and abbreviations not clearly resolved. If no items require review, print "None flagged." 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.)