At the bottom of the New York State C4 Form window is the Impairment box. Information that is specific to the patient about his/her ability to work must be entered. Note that the information entered in this box will determine whether or not this will be paid as a Workers’ Compensation claim.
The first question on the left of this box is Was injury described above the cause? Check this item when the cause of the injury/illness has been entered in the Where and how did injury/illness happen? box. Note that if this box is NOT checked, then the claim will be denied since the injury/illness is not related to the history given.
The next item is the First Day of Disability date field. Enter the first date on which the patient was NOT able to work due to the current injury/illness.
If the patient is working during the date range of visits for which this form is being prepared, place a check in the box next to Patient is Working. If the patient is working at a diminished capacity as a result of the injury/illness, also place a check in the box labeled Patient Disabled From Usual Work Activities. The check in the Patient Disabled From Usual Work Activities box also activates the middle right column with dot selections for Total Disability and Partial Disability. Click on either Total Disability or Partial Disability to make the choice. If the selected item is Partial Disability, then also click on the appropriate selection for Marked, Moderate, or Mild. It is critically important that the selection made here agrees with the percentage (%) entered in the Impairment Rating box on the lower left.
Note that when treatment begins, the patient may not be working at all so the Patient is Working and Patient Disabled From Usual Work Activities boxes would be blank for the C4.0 Initial Form. As treatment progresses, the patient may return to some less than normal level of work, which means the entry will require revision when the patient returns to work so that the proper entry will appear on the C4.2 Progress Form.
Impairment Rating is entered as a percentage (%). The scale that is used on this window is dictated by the State of New York. When entering the Impairment Rating be sure that the SOAP note and other documentation supports the percentage entered.
•0 to 25% = Mild partial disability
•26 to 50% = Moderate partial disability
•51 to 75% = Marked partial disability
•76 to 100% = Total disability
In the center of the Impairment box is the checkbox for Permanent Restriction, Total or Partial Loss. If it is determined that as a result of the work related injury/illness there is a permanent disability/impairment, place a check in this box and describe it in detail in the text box labeled If “yes”, Describe Restriction or Loss”. If there is no permanency, leave the box unchecked.
At the far right of the Impairment box is a checkbox for Patient Can Do Some Type of Work. In the event that the patient is able to do some type of work, even though he/she is impaired or disabled, place a check in this box. Then type in the type of work the patient is capable of performing in the text box labeled If “yes”, Describe Work Capacity.
After the form is completed, click the Save icon at the upper left.