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/ Nurse Case Management (NCM)
Progress Report

First report due fourteen (14) days after submission of Initial Care Management Plan.

Complete and return this form twice (2) per month throughout the acute care and initial recovery phase (0 ― 3 months).

Complete and return monthly through the rehabilitation phase (3 ― 18 months).

All fields marked with * are required fields.

Final Report
Company Name:
Assigned NCM / Provider Number
Date Referral Assigned / Dates Reporting / Estimated Date of Next Report
Demographic Information
Worker Name* / Date of Birth*
Worker’s Address / Worker’s Phone Number
Primary Language / Is a translator required?
Yes No
Designated Contact Name/POA/Next of Kin / Phone Number / Relation to Worker
Claim Information
Claim Number* / Date of Injury
Assigned ONC / ONC Phone Number / Assigned Claim Manager / CM Phone Number
Current State and Medical
Current Location / Expected Discharge Date
Brief Summary of Current State of Worker*
New Developments in Care
ICD-10 Codes and Up-to-Date Problem List
Organ-systems Based Functional Assessment*
Care Narrative*
Strengths and Challenges Assessment
Psychosocial and Economic Challenges* / Psychosocial and Economic Strengths*
Worker’s Transportation*
Vocational Profile
Vocational/Physical Challenges* / Vocational/Physical Strengths*
Employment Status*
Job Description*
Plan
Short Term Patient Centered Needs* / Long Term Patient Centered Needs*
Patient Provider Table
Provider Name / Provide Specialty / Provider Phone Number / Upcoming Appointment Date / Transportation Needed? / Claims Manager Notified?
Yes No / Yes No
Yes No / Yes No
Yes No / Yes No
Medical Files
Date Sent / Type of Record / Provider/Medical Facility Origin
Functional Assessment Table
Functional Assessment (Based on Type of Injury) / 0 ― 3 Month Date / 6 Month Date / 12 Month Date / 18 Month Date
NCM Log
Description of NCM Services Performed* / Billing Code* / Date Services were Performed* / Time Spent Providing Each Service*
(6 minutes = 1 unit) / Time Incurrent to Date on Referral*
(hours:minutes)
Additional Comments

F245-439-000 Progress Report 05-2017 Index: NCM