Permanent Work Related Mental Impairment Rating Report Work Sheet {WC-M3-PSYCH}

1. Activities of Daily Living Sexual Function:Sleep:required.2. Social Functioning ability to initiate social contacts with others, communicate clearly with others, interact and participate in 3. Thinking, Concentration and Judgment time it takes to complete the task, and extent to which assistance is required to complete the task. (Disability 4. Adaptation to Stress and time expectations. Further, the individual should demonstrate the capacity to follow rules and policies, medical and family areas. American LegalNet, Inc. www.FormsWorkFlow.com R C D G No Permanent Impairment. than everyday problems. Minimal Category of Permanent Impairment. Mild Category of Permanent Impairment. in social or work activities. Moderate Category of Permanent Impairment. impairment. Activities sometimes need direction or supervision. Marked Category of Permanent Impairment. or work activities. Extreme Category of Permanent Impairment. Maximum Category of Permanent Impairment. American LegalNet, Inc. www.FormsWorkFlow.com C D L EP W-R MI R R WSince the AMA Guides to the Evaluation of Permanent Impairment, 3rd Edition (Revised) does not provide a Disorders,224 the provider shall utilize this form. Patient Name þ WC # þ Date of Service þ Carrier # þ S: This form should only be used to determine an impairment after the case has been found to meet all of behavioral disorder impairments not likely to remit with further mental health treatment.aphysical impairment Stress. available.thephysician222s discretion may include the The extent to which medication ameliorates the effects of the worksheet. American LegalNet, Inc. www.FormsWorkFlow.com W Patient Name þ WC # þ Date of Service þ Carrier # þ N:behavioral disorder impairments not likely to remit with further mental healthtreatment. Further, impairment I.DSM Diagnosis:II.L PM I No permanent impairment 2. 3. 5. A FRate only impairments due strictly to the psychiatric condition. affective or anxiety disorders Sleep (restful sleep pattern)b. Interpersonal relationships Communicates effectively with others Participation in recreational activities (consider See attached Appendix for further description of all or part of the listed areas of function. American LegalNet, Inc. www.FormsWorkFlow.com c. Ability to perform complex or varied tasks Ability to abstract or understand concepts Memory, immediate and remote Perform simple, routine, repetitive tasks d. Adaptation to Stress Adapt to job performance requirements + divided by 2 = IV.F:Average the two highest Area of Function ratings:Add or subtract up to 0.5 from the completed calculation above, if appropriate, based on clinical judgment. Justify this deviation below or attach a separate sheet:Using the Category Conversion Table on page of this form, permanent impairment rating: If this patient has ZERO impairment according to the above criteriaand requires continuing medication for their DSM diagnosis, animpairment of 1-3% may be assigned %T IR(if applicable) Total Whole Person Physical Impairment = þ %Combined with psychiatric permanent impairment equals: þ þ þ þ þ Overall Category Rating: Permanent ImpairmentRating % If Zero % Psychiatric RatingRating % Total Whole Person Impairment (includingpsychiatric impairment)Rating % OR American LegalNet, Inc. www.FormsWorkFlow.com C C T Final Score2522.258 to 92.533.253.522 to 2333 to 3855.255.5 American LegalNet, Inc. www.FormsWorkFlow.com