During the initial assessment it is important to:

• develop a rapport with the injured worker
• time should be spent with the worker to understand the problem, this is a worthwhile investment in the overall health outcome, if more time is needed, a follow-up consultation should be scheduled
• establish the worker's medical history
• explore the relationship of the worker's injury to their work
• assess for red flags – identification of potentially serious conditions that require further investigation or specific treatment
• assess for yellow flags – these factors are considered important in the risk of an acute condition becoming chronic
• start a management plan
• provide a WorkCover Medical Certificate (previously known as a Prescribed Medical Certificate)

Complete a WorkCover Medical Certificate (WMC)

The WMC should be seen as an important tool to support the worker's management plan, and an element for review at the next consultation. It is useful to go though each section to make sure the worker also agrees on:

• the cause of the disability/disease
• the diagnosis
• the certification of incapacity/capacity.

It is important to:

• discuss physical restrictions and suitable work activities
• encourage the worker to talk with their employer or a rehabilitation and return to work coordinator at their workplace about suitable alternative duties
• consider that return to work strategies may include modified work, job rotation, job modification, the use of aids and equipment
• ask the worker what they can do rather than what they can't
• use the 'comments' section to convey other relevant information and information such as referrals made for treatment or investigation.

• Unless the initial assessment detects any serious conditions, plan to actively manage the injured worker.
• The extent of investigation, treatment and intervention varies with each circumstance and stage of care.
• On most occasions, radiological imaging studies are not required, however if considering the use of radiology, please refer to WorkCover's Imaging Guidelines.
• Discuss with the worker the diagnosis and prognosis and any activities the worker should include or avoid.
• Explain and reassure (convey optimism).
• Agree on a plan that includes symptom control, activity management, treatment and return to work.
• Involve the worker in the treatment and return to work planning.
• Identify communication needs and collaboration requirements.
• Set expectations with the worker including the timeline for recovery, goals and expectations of activity levels and functioning.
• Make an appointment for review.
• Document the baseline status and an action plan.

Current evidence generally favours active over passive treatment modalities, use of local modalities eg, application of heat/cold and simple analgesics. When prescribing medication or treatment:

• identify the goals, adverse effects and outcomes intended
• schedule a review to assess improvement.

An injury recovery care plan is an early intervention tool to assist in planning, documenting and following a structured clinical approach when managing any worker with a compensable injury (excludes those with serious injuries).

Understand the injured worker's work

• Talk to the worker about their workplace.
• If appropriate, access a rehabilitation and return to work coordinator.
• Consider a breakdown of tasks (ie, work task variability, job rotation).
• Consider safety (ie, use of safety equipment or work at heights).

Refer to the return to work page for more information.

• Note the time that has elapsed since the injured worker's date of injury.
• Assess progress against expectations including symptom level, control and functioning.
• Review original views
    - the diagnosis
    - yellow and red flags
    - expected progress
    - return to work
    - the worker's activity level and functioning (including feedback from others involved)
    - the worker's perceptions of treatment, diagnosis, prognosis and progress.
• Yellow and red flag issues may become more evident if there is lack of progress.
• Review the management plan and consider any small or major changes that may be needed.

Note: All services must be billed in line with the WorkCover Medical fee schedule.

If there is a delay in improvement conduct a full review, allow for a longer consultation time and:

• review the diagnosis
• review treatment objectives
• review the effectiveness of therapies and treatment and ensure treatment is clinically justified
• review red and yellow flags
• gauge the worker’s perspective
• contact other parties involved in the management of the worker
• consider arranging a case conference, workplace visit or workplace assessment
• if necessary, refer the worker to a medical specialist or psychologist
• continue to promote self-management techniques
• identify activity issues and problems
• set defined goals for the next few weeks
• consider the need for engaging a workplace rehabilitation provider
• update the management plan.

If progress has not met expectations at 12 weeks, consider the following:

• Do you have the correct diagnosis?
• Do you have the correct treatment?
• Do you require a second or specialist opinion?
• Is there an issue in the workplace not previously identified or resolved?
• stepping up the approach to care
• multi-factorial and interdisciplinary intervention – consider meeting all relevant health providers, the worker, the employer and case manager in a case conference
• a structured, supervised, active treatment program
• a structured return to work program, focused on a gradual increase in duties
• a referral for workplace rehabilitation (if not already underway)
• psychological intervention.