Psychologists working within the South Australian workers compensation scheme, also known as WorkCover or ReturntoWorkSA, may be requested by the claims manager or self-insured employer to provide a Comprehensive Report (fee schedule item PS810). This report type is used when a case is complex, involves co-morbidities or pre-existing conditions impacting recovery, or when the insurer has a significant number of questions requiring detailed information. It cannot be self-initiated — it must always be requested in writing by the claims manager, self-insured employer, worker, or worker’s representative.
This report template synthesises information from NovoNote and NovoPsych psychometrics to assist clinicians in preparing a comprehensive report in plain English that can be understood by ReturnToWorkSA claims managers and other decision-makers who may not have a medical or allied health background.
Note: NovoNote also includes the related template, ReturnToWorkSA Treating Psychologist Summary Report, for psychologists providing a Summary Report (fee schedule item PS820).
Treating Psychologist Comprehensive Report
Prepared under: ReturnToWorkSA Psychology Fee Schedule, Item PS810
Worker:
Date of Birth:
ReturnToWorkSA Claim Number:
Employer:
Date of Injury:
Date of Report:
Report Requested By:
Questions Addressed:
Diagnosis
History of the Work-Related Psychological Injury
Current Psychological Status
Co-morbidities and Pre-Existing Conditions
Other Contributing Factors
Summary of Treatment Provided
Progress in Treatment
Outcome Measures
Functional Capacity and Work Status
Self-Management
Future Treatment
Barriers to Recovery and Return to Work
Recommendations
Responses to Specific Questions
If you require any further information, please do not hesitate to contact me.
Yours sincerely,
Psychologist first and last name
AHPRA Registration Number
Practice Name
Treating Psychologist Comprehensive Report
Prepared under: ReturnToWorkSA Psychology Fee Schedule, Item PS810
Worker: James Brown
Date of Birth: 14/03/1981
ReturnToWorkSA Claim Number: RTW-2024-04471
Employer: Statewide Logistics Pty Ltd
Date of Injury: 22/08/2023
Date of Report: 26/03/2026
Report Requested By: Claire Nguyen, Claims Manager, ReturnToWorkSA
Questions Addressed:
1. What is the worker’s current diagnosis?
2. Is the worker’s current treatment appropriate and consistent with best available evidence?
3. What is the prognosis for return to work?
Diagnosis
Post-Traumatic Stress Disorder (PTSD), 309.81; Major Depressive Disorder, Moderate, 296.32.
History of the Work-Related Psychological Injury
James was involved in a serious workplace incident on 22 August 2023 in which he witnessed a co-worker sustain a severe crush injury while operating heavy machinery at a logistics depot. James was the first to respond and remained at the scene until emergency services arrived. Following the incident, he developed intrusive memories, nightmares, hypervigilance, and significant avoidance of the workplace and anything associated with the event. His symptoms progressively worsened over the following months, leading to cessation of work in October 2023 and a formal referral for psychological treatment in November 2023.
Current Psychological Status
James continues to experience moderate-to-severe PTSD symptoms including recurrent intrusive memories of the incident, distressing nightmares three to four nights per week, and marked hypervigilance in public environments. He reports persistent low mood, anhedonia, poor concentration, and fatigue consistent with moderate depression. Sleep is significantly disrupted, averaging four to five hours per night, and appetite remains reduced. Socially, James has withdrawn from friends and family and has not returned to any form of employment, reporting difficulty completing basic daily tasks. There has been some improvement in mood and nightmare frequency since commencing trauma-focused treatment, though James remains significantly impaired across multiple areas of functioning.
Co-morbidities and Pre-Existing Conditions
James has a pre-existing history of generalised anxiety, for which he received brief CBT approximately eight years ago; this condition had been in remission prior to the workplace incident. His treating GP has noted that the current psychological injury has reactivated and significantly exacerbated his anxiety symptoms, making them more treatment-resistant than they might otherwise be. The pre-existing anxiety is considered a contributing vulnerability factor; however, the workplace incident is the primary precipitant of the current clinical presentation.
Other Contributing Factors
James is experiencing significant financial stress as a result of his inability to work, which is contributing to his low mood and sense of hopelessness. He also reported relationship strain with his partner, who he describes as supportive but exhausted by the demands of his condition. These stressors are not causally related to the workplace injury but are compounding his psychological distress and slowing his recovery.
Summary of Treatment Provided
Treatment commenced on 14 November 2023, with 22 individual sessions provided to date at a frequency of weekly initially, transitioning to fortnightly from February 2025. The primary therapeutic modality is Trauma-Focused Cognitive Behavioural Therapy (TF-CBT), incorporating psychoeducation about trauma responses, cognitive restructuring of trauma-related appraisals, and graduated imaginal and in vivo exposure. Treatment has also incorporated behavioural activation to address depressive withdrawal and sleep hygiene strategies to address chronic sleep disruption. TF-CBT is the recommended first-line, evidence-based treatment for PTSD as per the Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder (Phoenix Australia, 2020).
Progress in Treatment
James has made meaningful progress since commencing treatment, with a reduction in the frequency and intensity of intrusive symptoms and improved ability to engage in daily activities. He is now able to drive short distances and attend appointments independently, which was not possible in the early stages of treatment. Mood has improved from severely depressed to moderately depressed, and James has re-established some social contact with one close friend. Progress has been gradual due to the severity of the initial presentation and the compounding impact of financial and relationship stressors.
Outcome Measures
PTSD Checklist for DSM-5 (PCL-5)
The reduction in PCL-5 scores indicates a meaningful decrease in trauma-related symptom severity since treatment commenced, though symptoms remain clinically significant.
Depression Anxiety Stress Scales – Short Form (DASS-21)
These results indicate moderate improvement across all three domains, consistent with James’s reported gains in functioning.
Trauma Recovery Measure (TRM)
Progress from early to middle stage of trauma recovery reflects meaningful movement through the recovery process, consistent with clinical observations.
Functional Capacity and Work Status
James is not currently employed and has not returned to work in any capacity since ceasing work in October 2023. His current psychological condition significantly impairs concentration, sustained attention, and emotional regulation, all of which are essential for his role as a logistics coordinator. He is able to manage basic self-care and household tasks with some difficulty but is not yet functionally capable of managing the cognitive and interpersonal demands of his pre-injury role. Improvement in daily functioning has been noted over recent months, suggesting capacity for graduated work reintegration may be achievable within the next three to six months with continued treatment.
Self-Management
James has developed a range of self-management strategies through treatment, including diaphragmatic breathing, grounding techniques for trauma cue responses, and a structured daily activity schedule to support behavioural activation. He is applying these strategies with moderate consistency and demonstrates a good understanding of the relationship between his symptoms and his avoidance behaviours. It is anticipated that James will be able to manage his condition with minimal professional support within approximately 12 months, contingent on continued progress and successful return to work.
Future Treatment
Planned Interventions: Future sessions will continue with TF-CBT, with increasing emphasis on in vivo exposure to workplace-related cues and graduated return to work preparation. Sessions will incorporate work-focused cognitive restructuring to address James’s fears about returning to the workplace environment.
Treatment Goals: By 30 June 2026, James will independently use at least two grounding strategies when exposed to workplace-related trauma cues, as measured by self-report. By 31 August 2026, James will successfully complete a four-week graduated return to work programme, attending at least three shifts per week without requiring unplanned leave. By 30 September 2026, James will report a PCL-5 score below the clinical threshold of 33, indicating sub-clinical PTSD symptom levels.
Number and Frequency of Sessions: 12 additional sessions are recommended at a fortnightly frequency.
Expected Duration: Approximately six months, with an anticipated treatment end date of September 2026.
Return to Work Alignment: The planned treatment directly targets the psychological barriers preventing James’s return to work, including trauma-related avoidance of workplace cues and fear of re-traumatisation. A graduated return to work is recommended to commence once James achieves stable symptom management, anticipated within three months. Prognosis for successful return to modified or full duties is cautiously positive given the progress made to date.
Anticipated Self-Management: James is expected to be able to self-manage his condition without ongoing professional support by approximately October to December 2026, subject to successful completion of the return to work programme and continued symptom reduction.
Barriers to Recovery and Return to Work
James’s persistent avoidance of workplace-related cues represents the primary psychological barrier to return to work and will require continued graduated exposure work. Financial stress and relationship strain are compounding his psychological distress and reducing his capacity to engage fully with treatment demands. There are currently no suitable modified duties available at his pre-injury employer, which limits options for a graduated return to work within a familiar environment.
Recommendations
Ongoing Psychological Treatment: Ongoing TF-CBT is recommended at a fortnightly frequency for a further 12 sessions over approximately six months. This treatment will directly address the persistent avoidance behaviours and trauma-related appraisals that represent the primary barrier to James’s return to work, in accordance with Phoenix Australia guidelines for PTSD treatment. This recommendation directly addresses the psychological barrier of workplace avoidance identified above.
Return to Work: A formal graduated return to work programme is recommended, commencing with low-demand duties at an alternative host employer if suitable duties are not available at Statewide Logistics. The programme should be developed in consultation with James, his treating GP, and the return to work coordinator, with a commencement target of July 2026. This recommendation directly addresses the barrier of unavailable suitable duties at the pre-injury employer.
Other Recommendations: A case conference is recommended between this clinician, James’s GP, and the claims manager to coordinate care and align return to work planning. Liaison with a return to work coordinator to identify suitable host employment options is also recommended. These recommendations directly address the practical barrier of limited suitable duties and the compounding impact of financial stress by supporting timely, coordinated return to work planning.
Responses to Specific Questions
1. James currently meets DSM-5-TR diagnostic criteria for Post-Traumatic Stress Disorder (309.81) and Major Depressive Disorder, Moderate (296.32), both of which are accepted as arising from the workplace incident of 22 August 2023.
2. The treatment being provided — Trauma-Focused Cognitive Behavioural Therapy — is the recommended first-line evidence-based intervention for PTSD as per the Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder (Phoenix Australia, 2020). The inclusion of behavioural activation and sleep hygiene strategies is appropriate given the comorbid depressive presentation.
3. Prognosis for return to work is cautiously positive. It is anticipated that James will be able to commence a graduated return to work programme within three months, with a view to achieving sustained return to modified or full duties by September 2026, subject to continued treatment progress and identification of suitable duties.
If you require any further information, please do not hesitate to contact me.
Yours sincerely,
Dr Sarah Brown
PSY0012345
NovoPsych Psychology Practice
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