FCEase Manual
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FCEase Manual |
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Company Letterhead
Name:
Address:
I.D. Number: (If Applicable)
Phone:
Age:
Medical Practitioner:
Phone:
Occupation:
Employer:
Address:
Contact:
Phone:
Referrer: (Rehab. Counselor: Private Ins.-Case Manager: Medical Practitioner)
Date Of Evaluation:
Evaluator:
History:
(WorkHab must appear on front page.)
Explain injury and injury date, brief history of what has occurred since injury date (i.e., hospitalization, treatment, surgery, therapy) mention employment status, how long have they been employed with employer, do they like what they do, feelings about being off work, do they get along with co-workers and boss. Are they fearful of being injured when they return to work, (RTW).
Results of previous Physical/Occupational Therapy evaluations, reason for performing the functional evaluation (i.e., slow improvement in return to work status, affect of residual pain goals for a vocational assessment in tertiary rehabilitation). Whether or not a worksite evaluation has been completed. Any difficulties they are currently having at their job, if still at work, but unable to perform all job demands.
Summary of Physical Evaluation
Results:
Include: current symptoms, PROM, AROM, muscle strength tests, neurological findings, any other significant signs or symptoms, cardiovascular risk analysis, and the fact that an F.C.E. is not contraindicated.
Test Performance:
Client performance, co-operation, ability to follow instructions, promptness, suitability of dress and behavior
Consistent or inconsistent findings - correlation to postures, pain behaviors, pain scales, BABI scores, blood pressure changes, grip strength testing, physical evaluation, F.C.E. specific testing, and diagnosis.
Summary of Test Results:
Refer to Result Sheet for complete performance results.
Critical Functional Abilities:
Explain in work related detail what this client can perform at the job site. Include time tolerances to postures, lifting abilities, distances, appropriate work heights, tolerance to an eight (8) hour day, cardiovascular endurance if job requires significant lifting or movement patterns.
Work desire as reported by client if positive.
Critical Functional
Limitations:
Summary
This section is where it all comes together, you as the clinician having the F.C.E. information has to be able to accurately correlate the testing information into some form of rehabilitation plan. Based on your understanding of the diagnosis, movement patterns, and the information provided by the F.C.E., you will need to make remarks on the following.
Should the client be in a rehabilitation program? Continue in the same program if currently attending one? If so, are there recommendations for issues which need to be addressed in the program (i.e., low cardiovascular level)? Should this client return to the safe job or is it highly unlikely? Should the client access additional rehabilitation services (i.e., a case manager)? If a worksite evaluation has not been performed, is this going to be additional information that will allow for a more accurate analysis?
Recommendations:
List these briefly and in chronological order based on the summary findings.
Report Writing:
The Report is the most important part of a Functional Capacity Evaluation. It contains essential sections that allows the reader of the report access to the following information:
Name of Client: and the particular details of the people involved in the case.
This is required in case the report becomes separated from the case file. It must be a 'free standing' report.
History: This may be brief or quite detailed depending on the circumstances. Try to be brief but as accurate as possible. The history should quickly formulate a picture of the client's case prior to testing.
Summary of Physical Evaluation (optional):
This may not be necessary however a brief evaluation should be done prior to testing to decide if any contraindications or precautions are present.
Test Performance:
A quick analysis of the evaluators observations and the client's behavior is extremely useful when summarizing the report.
Attitude, dress, promptness in attendance and willingness to co-operate all help in the determination of F.C.E. results. Consistency findings can be commented on here.
Summary of Test Results: Refer
to the Result Sheet for full details.
Use this section to highlight the very positive or very negative findings and relate to these in context with the rest of the report and recommendations.
For example: Results may show a high S.M.L. for floor to bench lifting but a low S.M.C. during carrying. This may not be inconsistent as the client had an ankle problem which altered the gait pattern over this distance but not during the lifting section.
Other observations made could be included in this section.
Critical Functional Abilities:
ALWAYS list these first before any limitations.
The F.C.E. should always try and focus on the abilities rather then the inabilities.
Explain some of the findings relative to the limitations. There may be some 'grey' areas not well explained in the Results Sheet.
Try to relate everything to the work environment where possible.
Positive motivational issues can be included in this section.
General Report Writing Hints
An accurate, well presented and useable report is the goal of any evaluator performing a F.C.E.
The golden rule is to supply a report that the referrer of the F.C.E. can quickly refer to for all the relevant answers.
Usually the questions are along these lines:
Can this client return to his/her job? If not, what are the hold ups?
Can he/she return to the job on a graduated basis using modified / selected duties and times?
What time frames are needed?
Are any modifications to equipment or work practices needed?
Are the problems likely to recur or produce long term restrictions?
Are the physical or mental job requirements suited to the client? Should a different placement be permanently sought?
At all times, try and relate the Results and Recommendations to the specific job requirements. If return to work (RTW) is not an immediate goal, be sure to outline the type of rehabilitation plan you feel is warranted. Included in this plan should be the order in which you feel the segments should be carried out, the goals you feel should be achieved, possible problem areas to be specifically addressed and finally the likely outcome of such a plan. Where possible, if appropriate, include estimated costs of such a plan to implement.
Remember, most of these decisions are to be made by non-clinical personnel who rely on your judgement in order to help make these decisions. An F.C.E. is an ideal way to pin point areas of concern - not only physical problems! F.C.E.s also provide a plan of action to overcome these concerns if possible.
These reports can be obtained by the client and it is recommended that the report is made easily available to ensure that the wording used is phrased carefully so as not to contain information that cannot be thoroughly backed up by your report. Be careful not to place 'labels' on clients or make diagnoses that are out of the realm of your expertise.
Try to keep in mind that the F.C.E. is for the use of other health professionals and, in some cases, non-health professionals so don't use a technical jargon particularly in the Results and Recommendations sections. If the report cannot be understood, it won't be of value.
Be aware that when writing a report, that it could end up as a valuable piece of evidence in a court of law and as a result may be critically evaluated. Caution and tact is required.
The high standards of your clinical facility may be judged by the promptness, presentation and contents of the report and most importantly the findings and recommendations contained within the evaluation.
Further help can be obtained by:
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