What the 10391A is for
The initial assessment report opens a worker’s episode in WSIB’s mild traumatic brain injury program of care, a community program for early treatment of non-complex concussion. The program runs eight weeks in two four-week blocks, with education, gradual return to activity, progressive exercise, manual therapy and vestibular rehabilitation. It has three reports: this initial assessment, a mid-point report and a care and outcome summary.
WSIB uses the report to confirm the worker fits the program and to set the baseline. The Rivermead Post-Concussion Symptoms Questionnaire and the Patient-Specific Functional Scale are required outcome measures, so the scores you record here are what later reports are compared against.
Who completes it
A regulated health professional registered to deliver the program completes and signs the whole report, usually a physiotherapist, chiropractor or occupational therapist. The form asks who made the mTBI diagnosis: a physician, nurse practitioner, or a WSIB Occupational Health Assessment Program physician. The worker answers questions in the assessment but has no part of the form to fill in.
How to fill in the report
A. Injured person and employer information
Record the worker’s details, date of accident, employer and supervisor, job title and time in the job. Tick full or part time, regular or modified duties and hours, and ask how long they expect it will take to return to full duties.
B and C. Provider and clinical information
Give your designation, facility and WSIB provider ID. Name who diagnosed the mTBI and when. Describe the mechanism of injury, loss of consciousness and its length, amnesia and early headaches. Record previous concussions in the last 12 months, mental health, substance use and neurological history, investigations and treatment to date, and the three most troublesome symptoms.
Physical findings, Rivermead and working diagnosis
Record musculoskeletal, neurological, balance and vestibular findings, including pertinent negatives, plus mental status and exercise testing where appropriate. Total the Rivermead score out of 64, excluding “other difficulties”. Give the working diagnosis and tick any complicating factors, such as fear of activity or work environment concerns.
D and E. Functional information and return-to-work accommodations
Score the Patient-Specific Functional Scale for three to five activities, at least two of them work-related, and give the average. Then record physical limits, symptom triggers such as screens, lighting and noise, and safety considerations such as driving or work at heights, each with a recommended accommodation.
F. Treatment plan and referrals
Tick the planned interventions, the expected duration in weeks and frequency per week, and give a rationale if you expect more than eight weeks. Record the education you gave and any referrals, such as WSIB’s mental health, neurology or return-to-work programs.
Common reasons it’s delayed or not paid
- Submitted more than 14 days after the assessment.
- A worker who doesn’t meet the program criteria, such as more than three months since injury.
- No diagnosing physician or nurse practitioner named.
- A missing Rivermead or PSFS score, or fewer than two work-related PSFS activities.
- More than eight weeks of treatment planned with no rationale.
Submitting and who pays
Submit the report through WSIB’s online services within two business days of the assessment. WSIB pays the provider the report fee and the treatment blocks under the mTBI program of care fee schedule, so the worker isn’t billed.