SAMPLE - Unsuccessful Closure Report template SLF training

Sample Reports

Unsuccessful Closure ReportSLF Training

388 Roncesvalles Ave, Suite 200 Toronto, ON M6R 2M9 T 866.226.9262 F 416.588.9235

www.banyanconsultants.com

Closure Report

(No RTW initiated)

From: (Add your name and title)

Arete Human Resources

Suite 210, 8180 Macleod Trail S

Calgary, AB, T1H 2B8

Telephone: 1-888-255-5196 ext

Fax: 1-403-252-6161

AUTOPOPULATED

CLAIMANT Mr John Doe D.O.B. March 2, 1960

CONTROL # 12345-00678-00 POLICY # 12345

ADDRESS 1001 Nowhere St. PHONE 987-654-3210

D.O.D. December 10, 2012 C.O.D. March 10, 2015

EMPLOYER Canada Post ACM Ms Smith

phone 123-456-7890

DIAGNOSIS

depressive episode OCCUPATION letter carrier

DATE of

FINAL

SESSION

February 27, 2013 REFERRAL

DATE

February 12, 2013

REPORT

DATE

May 12, 2013 Number of

sessions

until closure

report:

10

Arete Client Code: 12345 Professional ID: abcd

Therapists Estimate of RTW start date

(M/D/Y) (if changed since progress report,

please provide explanation)

July 2013, for explanation see below

Therapists Estimate of Client’s

probability of successful RTW (%): ( if

changed since progress report, please

provide explanation)

80%

Despite two sessions at work to solve conflict,

it is still not solved; a third meeting is

scheduled to take place May 25, 2013.

Client also sprained his ankle, is currently not

able to stand or walk and is seeing a

physiotherapist.

P a g e | 2



Resolved Barriers since Initial and Progress report

Barrier mentioned in

initial report

Comments/Explanation (if needed)

1) poor daily rhythm

client is able to get up at 8 am every day and eat three meals per

day and go to bed at 10 pm, client has a regular daily rhythm with

work, walks and household chores

2) poor self-care

client gets dressed every day and takes a shower every day

3) poor physical

stamina

client is consistent in following the exercise program and has

improved physical stamina

Ongoing Barriers to RTW (defined by therapist and discussed with client)

Summary of current

ongoing barriers (may

include symptoms, life

circumstance,

workplace issues,

addiction history or

any other influencing

factors)

Impact

Severity

(1)Mild

(2)Moderate

(3)Severe &

Serious

Observations

of impact on

RTW/

Solutions

Current treatment plan

1) work conflict

still existing barrier

moderate despite two

sessions at

work to solve

conflict, it is

still not solved

third meeting is scheduled on

May 25, 2013

2) client sprained ankle

new barrier

moderate client is

currently not

able to walk or

stand

client is seeing a

physiotherapist

Which homework tools have you utilized with client?

Stress Inventory Yes

Worrying assignment Yes

Time management No

P a g e | 3



Rationale tool Yes

Writing/Journaling assignment Yes

Anti-depressant skills No

Handouts Managing Anger, Managing

Worry, Relationship building, Relaxation

Skills

Yes managing worry and relationship

building

if Yes, which handout

Other Please List: thought records

If you have not used home work tools,

please provide explanation and

suggestions

Which other tools have you used in preparing client for RTW and increasing RTW

self efficacy?

Roleplay

Overall Evaluation of Treatment:

Client’s Progress in Resolving barriers to RTW: (provide explanation/suggestions for

improvement)

None Low Moderate Good Very Good

0__________________________x______5________________________________10

Evaluation/suggestions: client is having physiotherapy and a new meeting to solve

conflict is scheduled

Client’s Level of Engagement in Resolving barriers to RTW: (please provide

evaluation)


0_________________________________5_________x______________________10

Evaluation/suggestions: client is actively participating

Client’s progress with self efficacy efforts: (please provide evaluation and suggestions

for improvement)


0_________________________x_______5________________________________10

Evaluation/suggestions: after unsuccessful meetings to solve work conflict client felt less

confident in RTW but client experienced that he is able to deal with unhelpful thinking

Third meeting needs to take place, is scheduled May 25, 2013.

P a g e | 4



Rate the progress in increasing client’s overall functioning thus far: (please provide

evaluation)


0________________________x________5________________________________10

Evaluation/suggestions: Client initially made good progress when it appeared that the

conflict was solved, when it became clear that further meetings were needed, client

experienced a setback in unhelpful thinking. Client also sprained his ankle and is currently

not able to walk or stand or participate in the exercise program.

Has client worked with the online diary? (Please provide evaluation)

Not at all Sometimes Daily

0__________________________________5_______________________x_______10

Evaluation/suggestions: none

Has client participated in the individual exercise program or increased physical

activity otherwise? (Please provide evaluation)

Not at all Sometimes Daily

0__________________________________5______________________x________10

Evaluation/suggestions: client is currently not participating in exercise program but has

been very active prior to sprained ankle

Overall Treatment Conclusion and summary analysis key factors

contributing to unsuccessful RTW outcome:

Client is currently not able to start a GRTW for the following reasons.

Client needs to recover from the sprained ankle; client is currently not able to work on

physical stamina and is attending sessions with the physiotherapist.

Work conflict also still needs to be solved. A third meeting is scheduled for May 25, 2013.

Client has learned tools to be able to assist him with having a successful RTW. Client needs

to continue to work with thought records and worry assignment. Client is still not able to get

up at 6 am but is improving.

Client has been actively participating in the program, filled out the online diary and

participated in the exercise program.

It is expected that a successful RTW can start in July 2013.

Specific Input for RTW Coordinator or Case Manager: (elements that need to be

addressed/considered)

Client needs to be provided with time to recover from sprained ankle.

Client might need assistance if the third meeting to solve the conflict is also not successful.

Client can start RTW in July 2013 if conflict is solved and recovered from sprained ankle

Documents

SAMPLE - Unsuccessful Closure Report template SLF training