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Permanent Work Related Mental Impairment Rating Report Work Sheet WC-M3-PSYCH - Colorado
| Permanent Work Related Mental Impairment Rating Report Work Sheet Form. This is a Colorado form and can be used in Workers Comp . |
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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Division of Workers Compensation PERMANENT WORK-RELATED MENTAL IMPAIRMENT RATING REPORT WORK SHEET rd Since the AMA Guides to the Evaluation of Permanent Impairment, 3 Edition (Revised) does not provide a quantified method for assigning permanent impairmenrcentages t pe under Chapter 14, Mental and Behavioral Disorders, the provider shall utilize this form. Patient Name Date of Service: WC # Carrier # SCORING INSTRUCTIONS: 1. This form should only be used to determine an impairment after the case has been found to meet all of the specific criteria for a DSM IV diagnosi s. rd 2. The AMA Guides to Permanent Impairment, 3 Edition (Revised) should be consulted for guidance in determining these ratings. 3. Determination of a rating of permanent mental or behavioral impairment shall be limited to mental or behavioral disorder impairments not likely to remit with further mental health treatment. 4. Impairment ratings based on chronic pain are not applicable within the mental/behavioral domain, but are restricted to physical examination with evidence of anatomic or physiologic correlation and included within a physical impairment rating. 5. To obtain the final overall impairment rating: a. The elements to be rated are divided into four Areas of Function: Activities of Daily Living; Social Functioning; Thinking, Concentration and Judgment; and Adaptation to Stress. b. Assign a rating (0-6) to each subcategory of the areas of function based on patient self-report, other sources of information, and the physicians clinical asssment. Given the se heavy reliance on the patients subjective report for information in some of the ratings, the physician should give careful consideration to any corroborating evidence that might be available. c. Average the two highest subcategory ratings within each Area of Function to obtain the overall category rating. For example, if the two highest scores are 2 and 5, the category score is 3.5. d. To calculate the overall impairment rating, average the two highest category ratings and then, if appropriate in the case, use clinical judgment to add or subtract up to 0.5 point from the result. If the score is modified in this fashion due to clinical judgment, justification for doing so must be documented. Factors influencing the physicians discretion may include the following: i. Factors influencing the patients believability, such as the presence of symptom magnification, or the presence or absence of corroborating information from psychological or neuropsychological testing; ii. The extent to which medication ameliorates the effects of the condition; e. Use the Category Conversion Table in these instructions to convert the final number to a percentage. 6. Include the DSM-IV diagnosis at the top of the worksheet. Rev. 03/02 WC-M3-Psych 1 <<<<<<<<<********>>>>>>>>>>>>> 2The final determination must include ratings for all of the eleents im n each area of function, the category averages reached in each area of function, the overall average, the final assigned overall permanent impairment rating, and documentation for any divergence (0.5) from the calculated score. CATEGORY CONVERSION TABLE Final Score Percentage 0 0 0.25 0 0.5 1 0.75 1 1 1 1.25 2 1.5 3 to 4 1.75 5 2 6 to 7 2.25 8 to 9 2.5 10 to 12 2.75 13 to 15 3 16 to 18 3.25 19 to 21 3.5 22 to 23 3.75 24 to 25 4 26 to 32 4.25 33 to 38 4.5 39 to 44 4.75 45 to 50 5 51 to 56 5.25 57 to 62 5.5 63 to 68 5.75 69 to 75 6 76 to 83 6.25 84 to 91 6.5 92 to 100 7. If apportionment is applicable, complete a separate fo calculating the pre-injurm ry rating to be subtracted from the total current rating. 8. If there is a finding of no impairment, refer to Part V on the worksheet, if appropriate. Rev. 03/02 WC-M3-Psych 2 <<<<<<<<<********>>>>>>>>>>>>> 3 WORKSHEET Patient Nam e Date of Service: WC # Carrier # NOTE : Determination of a rating of permanent mental or behavioral impairment shall be limited to mental or behavioral disorder impairments not likely to remit with further mental health treatment. Further, impairment ratings based on chronic pain are not applicable within the mental/behavioral domain, but are restricted to physical examination with evidence of anatomic or physiologic correlation and included within a physical impairment rating. I. DSM-IV Diagnosis: Axis I: Axis II: II. LEVELS OF PERMANENT MENTAL IMPAIRMENT Suggested % Category 0% 0. No permanent impairment 1-5% 1. Minimal Category of Permanent Impairment 6-15% 2. Mild Category of Permanent Impairment 16-25% 3. Moderate Category of Permanent Impairment 26-50% 4. Marked Category of Permanent Impairment 51-75% 5. Extreme Category of Permanent Impairment 76-100% 6. Maximum Category of Permanent Impairment 1 III. AREAS OF FUNCTION 1. Activities of Daily Living. Rate only impairments due strictly to the psychiatric conditio n. 0 1 2 3 4 5 6 Self care and hygiene (dressing, bathing, eating, cook ing) 0 1 2 3 4 5 6 Travel (driving, riding, flying) i.e. impairments in driving, riding, flying which are generally a result of symptoms of affective or Overall Category Rating: (average of 2 highest) anxiety disorders 0 1 2 3 4 Sexual function (participating in usual sexual activities) 0 1 2 3 4 Sleep (restful sleep pattern) 2. Social Functioning 0 1 2 3 4 5 6 Interpersonal relationships Overall Category Rating: 0 1 2 3 4 5 6 Communicates effectively with others (average of 2 highest) 0 1 2 3 4 5 6 Participation in recreational activities (consider pre-injury activities of the patient) 0 1 2 3 4 5 6 Manage conflicts with others--negotiate, compromise 1 See attached Appendix for further description of all or part of the listed areas of function. Rev. 03/02 WC-M3-Psych 3 <<<<<<<<<********>>>>>>>>>>>>> 4 3. Thinking, Concentration & Judgment 0 1 2 3 4 5 6 Ability to perform complex or varied task s 0 1 2 3 4 5 6 Judgment 0 1 2 3 4 5 6 Problem solving 0 1 2 3 4 5 6 Ability to abstract or understand concepts 0 1 2 3 4 5 6 Memory, immediate and remote Overall Category Rating: (average of 2 highest) 0 1 2 3 4 5 6 Maintain attention, concentration on a specific task 0 1 2 3 4 5 6 Perform simple, routine, repetitive tasks 0 1 2 3 4 5 6 Comprehend/follow simple instructions 4. Adaptation to Stress 0 1 2 3 4 5 6 Set realistic short & long term goa ls Overall Category Rating: 0 1 2 3 4 5 6 Perform activities (including work) on schedule (average of 2 highest) 0 1 2 3 4 5 6 Adapt to job performance requirements IV. FINAL CALCULATION
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