Can I write that work caused the condition?

Give your clinical opinion on the relationship between the workplace events and the condition, with your reasoning, and use the scheme's own words where you can (schemes speak of a significant, substantial or major significant contributing factor, and the test differs between them). The legal conclusion on liability is the insurer's to draw. A report that states the clinical opinion clearly and shows its reasoning is far more useful than one that asserts the legal conclusion.

The history involves performance management. How do I handle that?

Describe the events factually, with dates, and label the worker's account as the worker's account. Every scheme excludes injury arising from reasonable management action taken in a reasonable way, and whether that exclusion applies is the insurer's decision, but they cannot make it without an accurate chronology. Do not argue the point in either direction; set out what happened and what followed clinically.

Should I include pre-existing history?

Yes, and address its relevance. The insurer will obtain the prior records anyway, and a report that omits a known history loses credibility on everything else it says. State what pre-dated the injury, whether it was symptomatic, and your view on how the workplace events relate to the current presentation.

How specific does capacity need to be?

Specific enough to be turned into a return-to-work plan: hours per day and days per week, the duties the worker can and cannot perform, the restrictions that apply (for example no contact with a named colleague, no client-facing work, no night shifts), the expected duration, and a review date. "Unfit for the foreseeable future" is not a capacity statement; it is a prompt for an independent examination.

Who assesses permanent impairment?

Trained and accredited assessors under each scheme's impairment guidelines, once the condition has stabilised. The treating psychiatrist is usually asked whether the condition is stable and may be asked for a treating-doctor opinion; the assessment itself is a separate document, for which PsychDispatch has a separate preset.

Who pays for the report?

Generally the insurer that requested it, at the scheme's published fee schedule, and the fee usually depends on which report type was requested. Confirm the request, the report type and the fee before writing, and answer the questions the insurer actually asked.

The treating psychiatrist's WorkCover report: causation, capacity and treatment the insurer can approve

What this report is for

The reader is a case manager at the insurer or scheme agent, working through a claim, and possibly a lawyer at a later stage. They are not clinicians, and they are not deciding treatment. They are deciding whether to accept liability, whether to approve the treatment you propose, what the worker can do, and when they might return to work. The report is medical evidence in that process, which changes its tone: factual, independent, sourced, with the worker's account labelled as the worker's account and your findings labelled as yours.

Australian workers' compensation is run by the states and territories and by Comcare federally, and the schemes differ on the words they use for causation, the forms they publish and the fees they pay. Several publish a treating-psychiatrist report template or ask specific questions in their referral. Where they have, answer those questions in their order under their headings; the structure below is what to do when they have not.

The four questions the insurer is deciding

Is the condition work-related under this scheme's test? The schemes speak of a significant, substantial or major significant contributing factor, and every one excludes injury arising from reasonable management action taken in a reasonable way. Your job is the clinical opinion and its reasoning, in their words where possible; the legal conclusion is theirs.
Is the proposed treatment reasonably necessary, and related to the injury? Modality, frequency, duration, goals and how progress will be measured. This is what approval is granted against.
What is the worker's current capacity? Fit, unfit, or fit with restrictions, in terms that can be turned into a plan.
What is the prognosis, and when might they return? A timeline, the barriers to it, and a review date.

What it must contain

The request. Who asked for the report, what they asked, the claim number, and the documents you reviewed. Reports that answer a different question from the one asked are sent back.
Your standing. Treating psychiatrist since when, number of consultations, date last seen.
The history of the injury. A dated chronology of the workplace events as reported by the worker, labelled as such, and the onset and course of symptoms in relation to them.
Pre-existing and concurrent conditions. What pre-dated the injury, whether it was symptomatic, other stressors, and your view of their relevance.
Examination. Mental state on examination, and the findings that support the diagnosis.
Diagnosis. In the terms of a recognised classification, with the criteria met, and the differential where it matters.
Causation. Your clinical opinion on the relationship between the workplace events and the condition, with reasoning, in the scheme's language where you can use it honestly.
Treatment. What has been provided and with what response; what you propose, with modality, frequency, duration, goals and outcome measures; why it is reasonably necessary and related to the injury.
Capacity. Hours and days, duties that can and cannot be performed, specific restrictions, expected duration, review date.
Prognosis and return to work. Expected course, barriers to recovery and to return (clinical, workplace, personal), what would help, and whether the condition has stabilised.

Causation, carefully

This is the section that decides claims and the one most often written badly. Three habits keep it defensible. First, separate the account from the finding: "Mr X reports that on [date] ..." is the account; "on examination ..." and "in my opinion ..." are yours. Second, show the reasoning: the temporal relationship, the absence or presence of other explanations, the consistency of the presentation with the reported events. Third, use the scheme's words only where they are true. A clinical opinion that the workplace events were a significant contributing factor, with reasoning, will be read; a bare assertion that "this is a work-related injury" will be tested.

Where the chronology includes performance management, discipline or dismissal, describe it factually and let the insurer apply the exclusion. Arguing it either way weakens the report.

Where reports fall short

Causation is asserted without a dated chronology or any reasoning behind it.
The worker's account is written as established fact.
Pre-existing history is omitted, and turns up in the records the insurer obtains anyway.
Capacity is "unfit for the foreseeable future" with no restrictions and no review date, which invites an independent examination.
The treatment request names a modality with no frequency, duration, goals or outcome measure, so it cannot be approved as written.
The report answers questions the insurer did not ask, and misses the ones it did.
The tone is advocacy, which costs the report its standing as evidence.
It arrives after the decision it was meant to inform.

A skeleton that works

[Insurer or agent], Attention [Case manager]

Re: [Worker], DOB [date]. Claim number [number]. Employer [employer].

Request and documents. This report responds to your request of [date] for [report type]. In preparing it I have reviewed [documents].

Treating clinician. I have treated [Worker] since [date] and have seen them on [n] occasions, most recently on [date].

History of injury. [Dated chronology of workplace events as reported by the worker; onset and course of symptoms.]

Pre-existing and concurrent conditions. [What pre-dated the injury, its status, other stressors, relevance.]

Examination. [Mental state examination and supporting findings.]

Diagnosis. [Diagnosis in classification terms, criteria, differential.]

Opinion on causation. [Clinical opinion, reasoning, scheme's language where honest.]

Treatment. Provided to date: [...]. Proposed: [modality, frequency, duration, goals, outcome measures]. In my opinion this treatment is reasonably necessary as a result of the injury because [...].

Capacity. [Hours and days; duties; restrictions; duration; review date.]

Prognosis and return to work. [Expected course; barriers; what would assist; stability.]

[Name, qualifications, AHPRA registration number, provider number, date]

The other WorkCover documents

The initial report is one of a family, each with its own preset. The capacity certificate is the scheme form that certifies fitness for work and is separate from the report. The initial treatment request and treatment approval renewal ask for funding of a defined course of treatment and are read against the same reasonably-necessary test. The progress report updates the insurer on response and capacity, and should lead with what changed. The return-to-work plan turns capacity into duties, hours and dates. The permanent impairment assessment is a separate discipline for accredited assessors once the condition has stabilised.

How PsychDispatch drafts this

The WorkCover - Initial Treating Psychiatrist Report preset drafts the report in the structure above, and verification does its most important work here: every clinical statement in the draft is traced to the transcript before you sign it, which is the discipline a document headed for a claims file needs. Patient Intelligence supplies the dated chronology, the treatment provided and the response to it, and the functional trajectory across consultations, so the causation and capacity sections rest on what was documented at the time rather than on recollection.