THE WORK COMP PT
Free field guide · for outpatient PTs, OTs & ATCs
The Work Comp Note Cheat Sheet
What to put in every work-comp note so the claim gets paid, the reviewer stays off your back, and the case actually moves toward a close.
A work-comp note is not an ortho note. People you'll never see in the clinic decide the case from
your documentation alone — the physician who sets the work restrictions, the adjuster, the
utilization reviewer, and sometimes an attorney. Write every note for them, and you stop losing
visits, denials, and hours to the back-and-forth.
Every WC note needs these 6 things
Objective, functional, job-referenced measures. Not pain and ROM alone — where they are against the job's real demands (lift 20 lb to waist, stand 2 hrs, reach overhead).
The gap between current function and the job. This is what justifies continued skilled care. Name it explicitly.
Measurable change since the last note. Progress = medical necessity. No change, no note-worthy reason to keep going — say what you're changing.
Current work status & demonstrated abilities. Every visit. You don't set restrictions — the physician does — but your objective abilities data is what lets them update the restrictions accurately and on time.
The plan and an expected discharge target. Shows you're driving to a close, not drifting. A case with no end date is a case that gets cut.
Barriers — and what you're doing about them. Name the delay before the reviewer does, and own the next step.
Get paid: do & don't
Do
- Tie every goal to a specific job demand
- Quantify function and tolerance ("sat 45 min before onset")
- Report demonstrated abilities so the MD can update restrictions
- Document the skilled reasoning, not just the exercise
- Write the discharge target early and update it
Don't
- "Continue POC" as your assessment
- Pain-only or ROM-only progress notes
- Vague goals ("improve strength / tolerance")
- Passive-modality-only visits with no progression
- Go silent on work status — it reads as no plan
Give the physician what they need to update restrictions
Weak "Patient tolerated treatment well and continues to progress."
Strong "Demonstrated today: floor-to-waist lift 20 lb ×10, sustained sitting 45 min without symptom onset, overhead reach to 150°. Current capacity remains below the job's 50-lb lift / frequent-overhead demand."
You don't write the work restrictions — the physician does. But when your note reports objective,
job-referenced abilities, the physician can update restrictions promptly and accurately instead of guessing
from a brief exam. Timely, function-based restriction updates = faster safe return-to-work = a case that moves.
Red flags a case is stalling
Two-plus visits with no functional change
Visits drifting to pain talk, not progress
Restrictions unchanged for weeks
Missed or rescheduled appointments
"Flare-ups" with no objective correlate
No discharge target anywhere in the chart
This is one page of the whole playbook.
The note is where cases are won or lost — but it's one piece. Documentation, return-to-work, working the
adjuster, the stalled case, closing clean: that's Work Comp Confident, opening now to a small founding cohort at the founder price.
Join the founding cohort → theworkcomppt.com