EQUIPMENT PRESCRIPTION FORM NOTES
The Equipment Prescription form does not need to be completed for the following equipment: pick-up sticks taping (zinc oxide, fixomull, strapping, etc.) oedema control and dressing bandages hand putty/thera-putty digiflex, exercise foam plaster, ice packs, heat packs dressing aids silicone gel sheeting (one 10x13cm sheet only) bandages (compression, tubigrip, thera-band, gauze thermal supports, pressure garments and gloves products) hibitane, iso-wipes, skin-prep, applicators walking sticks non-electrical adapted cleaning equipment (up to $150 per triangular slings item only).
This form must only be completed for the following equipment
. Wheelchairs . Recumbent trikes . Large exercise equipment . Pressure cushions . Beds . Lounge chairs / tilt recliners . Powered conversion kits . Mattresses . Custom toilet / shower / commode chairs . Hoists . Standing frames . Shower trolleys . Scooters . Tilt tables . Mainstream multifunctional technology (i.e. tablets, smartphones, computers. etc.) . Bikes . Treatment couches . Ramps . Any other single item that exceeds $1,500.00.
All other types of equipment requests must contain the following information:
. Summary of the client/worker’s injuries and equipment needs . Details of the relationship between the equipment and transport accident injury/work-related injury or illness . Details of the specific equipment item, function, and intended use . the duration and expected use of the equipment . the cost of the equipment.
All the above points must be addressed for an equipment request to be considered by the TAC/Worksafe.
Note for Hospitals Wheelchairs, toilet/shower/commode chairs . The Equipment Prescription Form should be used for customised chairs to be hired or purchased . The Hospital Direct Order Form should be used for the immediate provision of a hired wheelchair or toilet/shower/commode chair on discharge. 1. Your details . Specify if you are a contracted (Benefit and Support Services Assessor (BASSA), or Network Occupational Therapist) or a non- contracted community occupational therapist. . All other health professionals, such as physiotherapists, are not required to complete this section. You are required to complete section 14 only. 2. Client/Worker details . Complete the client/worker details. 3. Current level of function . List the client/worker’s: . injuries . relevant medical history . social situation
WorkSafe Victoria is a trading name of the Victorian WorkCover Authority
EQUIPMENT PRESCRIPTION FORM NOTES
. specific functional limitations, and . current functional status as they relate to your request.
Include pre-existing conditions and/or non-accident or work-related injuries which may affect the client/worker’s current condition.
4. Clinical justification . Identify the purpose of the recommended equipment. Identify intended use (indoors, outdoors, frequency) . Detail the expected measurable outcomes that will be achieved, including the maximisation of functional independence and the support of clinical outcomes.
5. Discussion with treating healthcare professionals . Include all discussions undertaken with the client/worker’s other treating healthcare professionals, including differences in opinion or support for your recommendations. 6. Trials Please note that the trialling of products from the Equipment List and/or equipment contractors is mandatory. Failure to do so without clinical justification will result in the Equipment Prescription Form being returned. You can access the Equipment List on the TAC’s website at www.tac.vic.gov.au or at WorkSafe’s website at www.worksafe.vic.gov.au Providers need to contact the equipment contractors prior to conducting trials of equipment. You can find equipment contractor contact details at the top of the Equipment Prescription Form. Details of the trial . Include details of all equipment trialled, including the specific item you are recommending . Include length and location of trial and the equipment provider’s name, e.g. client/worker’s home or workplace . Detail why each item is appropriate/inappropriate, including clinical justification for the equipment you recommend in section 7.
7. Details of recommended equipment . List specific details of the recommended equipment. Include model and specification. The Equipment List should be your first consideration when recommending equipment . List non-standard options and customisations that need to be made to a base model. These must be based on clinical need. Check-boxes . Consider day-to-day transportation of the equipment . Consider the compatibility with existing equipment and the client/worker’s environment . Consider the client/worker and carers safety with this equipment . Consider if multidisciplinary team consensus is required . Consider if the equipment is available from the equipment contractors. If not, the Claims Manager will refer the order to the Equipment Brokerage Team. Provide more information if the answer to any of these check-boxes is ‘no’. Method of equipment provision . Specify if your request is a purchase or hire. Hire may be suitable if the client/worker’s condition is likely to change and/or the item is required for a short time . If recommending hire, please consider the hire length and whether the purchase of the item is a more cost effective option. Type of supply . Specify if the type of supply is initial, a replacement, or modification . Detail the type and model of current equipment, and the date purchased . List the limitations of current equipment . Detail the reason for replacement of the equipment. 8. Quotation Quotes are only required for customised items and items not on the Equipment List
WorkSafe Victoria is a trading name of the Victorian WorkCover Authority EPF1N 03/14
EQUIPMENT PRESCRIPTION FORM NOTES
9. Anticipated maintenance . Specify the equipment warranty and recommended service schedule. Consider the warranty and the supplier’s recommended service schedule. 10. Training requirements . Outline any required training for the client/worker and/or carers. 11. Equipment review . It is expected that a review of the equipment will be conducted by the prescribing therapist after delivery . If a review will not be conducted please specify the reason. 12. Benefit and Support Services Assessor only . This section is only to be filled out by a Benefit and Support Assessor. Network and Community Occupational Therapists are not required to fill in this section. 13. Additional comments . Please attach any other information which you believe to be relevant. 14. Prescribing Occupational Therapist or health professional details . Include therapist’s name if using practice stamp . The therapist’s signature is mandatory for the TAC/Worksafe to accept the Equipment Prescription Form.
WorkSafe Victoria is a trading name of the Victorian WorkCover Authority EPF1N 03/14