medEbridge® | QBE

IMPACT Clinical Summary Form

This form is to be used by GPs to report on each consultation remunerated under the IMPACT Program.

Note: Alternatively, you can download our interactive PDF version of this form.

QBE

GP details

GP Name *

GP Practice Name *

GP Program ID

Patient details

QBE Claim No

Name *

First name

Last *

Last name

Date of Birth *

Gender * Gender

Consultation details

(This is the reason for your patient presenting today.)

Date of this consultation

Patient consultation type

(select all that apply)

Initial Assessment

Pain Management Planning

Consultation remuneration eligibility check

Patients must be:

18 years of age and over,
Covered by a QBE Workers Compensation policy,
have a current experience of pain,
be within 3 months of injury onset,
be at high-risk of an opioid prescription but not be dependent on opioid medication for consultations to be remunerated.

Eligibility criteria met

Please tick this box to confirm that the patient meets the eligibility criteria

Assessment of patient

Check which domains are of concern for this patient, which domains you made a referral to another provider for, and which domains you have recommended patient active self-management for [check all that apply]

Harmful structural contribution

Of Concern? (tick if yes)

Referral made or Investigation ordered

Active patient self-management discussed

Social functioning

Of Concern? (tick if yes)

Referral made or Investigation ordered

Active patient self-management discussed

Occupational functioning

Of Concern? (tick if yes)

Referral made or Investigation ordered

Active patient self-management discussed

Mood

Of Concern? (tick if yes)

Referral made or Investigation ordered

Active patient self-management discussed

Anxiety

Of Concern? (tick if yes)

Referral made or Investigation ordered

Active patient self-management discussed

Other mental health

Of Concern? (tick if yes)

Referral made or Investigation ordered

Active patient self-management discussed

Physical activity

Of Concern? (tick if yes)

Referral made or Investigation ordered

Active patient self-management discussed

Nutrition

Of Concern? (tick if yes)

Referral made or Investigation ordered

Active patient self-management discussed

Sleep

Of Concern? (tick if yes)

Referral made or Investigation ordered

Active patient self-management discussed

Alcohol

Of Concern? (tick if yes)

Referral made or Investigation ordered

Active patient self-management discussed

Cigarette smoking

Of Concern? (tick if yes)

Referral made or Investigation ordered

Active patient self-management discussed

Recreational drug use

Of Concern? (tick if yes)

Referral made or Investigation ordered

Active patient self-management discussed

Referrals

Please list the healthcare provider types you have referred the patient to (e.g. physiotherapy)

Prescriptions

Was an opioid prescribed for this patient in this consultation?

Yes

No

Type

Dose

Have you established with the patient a maximum dose and timeframe for opioid use?

No, I have not established maximum dose or maximum timeframe

Yes

Maximum Dose:

Maximum Timeframe:

Was another schedule 8 medication prescribed for this patient in this consultation?

Yes

No

Type:

Dose:

Is the patient currently taking an opioid medication (that was not prescribed in this consultation)?

Yes

No

Does the patient currently have a prescription for medicinal cannabis or cannabinoids?

Yes

No

Have you checked TasScript for opioid prescriptions for this patient?

Yes

No

If there are issues of opioid dependence with this patient, the consultations for this patient are not eligible for remuneration. [https://www.tasscript.health.tas.gov.au/]

Program Requests

Would you like to request a case consultation with the program’s pain management specialist in relation to this patient?

Yes

No

Would you like to request case coordination support for this patient?

If yes please also advise the patient of your request.

Yes

No

If yes, please indicate which healthcare providers you would like our case coordinators to connect you with: