Victorian WorkSafe Documentation for Allied Health: A Practitioner Guide

The Clinical Framework

WorkSafe Victoria and the TAC jointly published the *Clinical Framework for the Delivery of Health Services* (2012, periodically refreshed). It sets five principles every allied health intervention must demonstrate:

1. Measure and demonstrate the effectiveness of treatment.
2. Adopt a biopsychosocial approach.
3. Empower the injured person to manage their injury.
4. Implement goals focused on optimising function, participation, and return to work.
5. Base treatment on the best available research evidence.

Documentation that does not show these principles being applied is the most common reason for an extension request being declined.

Initial assessment documentation

The initial assessment is the foundation. It must include:

• Worker identification — full name, claim number, employer.
• Referral and date of injury — claim acceptance status, date of injury, mechanism of injury.
• Presenting problem — pain location and behaviour, functional limitations, psychological symptoms (if present).
• Pre-injury baseline — work demands (lifting weights, hours, postural demands), pre-injury fitness and function, prior injuries.
• Current activity tolerance — measured (not just reported) where possible.
• Goals — function-based, time-bound, return-to-work-aligned. "Return to full pre-injury duties within 12 weeks" is appropriate; "reduce pain" is not.
• Treatment plan — modality, frequency, expected duration, expected outcomes.

Progress report content

Progress reports are due as scheduled in the original treatment plan and on request from the WorkSafe Agent. They must show:

• Sessions provided since the last report (date, duration, focus of each).
• Outcome measures — comparison to baseline using validated instruments (e.g. PSFS, NDI, ODI for musculoskeletal; DASS-21, K10 for psychological).
• Functional gains — specific, observable improvements in capacity tied to the original goals.
• Return-to-work activity — graduated return-to-work plan progress, employer communication, hours worked.
• Plan adjustments — what is being added, removed, or modified, and why.

Extension requests

Requests for additional treatment beyond the initial block must answer three questions:

1. What measurable improvement has the previous block delivered?
2. Why is further treatment expected to deliver further measurable improvement?
3. What is the expected end-point — when does treatment finish?

Extension requests without measurable baseline-to-current data are routinely declined.

When the worker does not improve

Documentation must be honest about plateau. A note that records "no further improvement in functional capacity over the past 4 sessions; recommend transition to self-management and discharge" is defensible. A note that conceals plateau and continues billing is the kind of practice that triggers a WorkSafe audit.

Common audit failures

• Goals worded as treatment activities ("complete 10 sessions of physiotherapy") rather than functional outcomes.
• Outcome measures named but not actually scored at baseline.
• Progress reports that read like session-by-session diaries with no comparison to baseline.
• Extension requests with no end-point specified.
• Communications with the employer or treating doctor mentioned but not documented.

Related reading

• Functional Capacity Evaluations: WorkCover and TAC OT Documentation
• EAP Session Documentation: Employer Reporting for Counsellors