LEX 60445 - Decision - Final Documents

LEX 60445 - Administrative Release - Page 2 of 15
Your reference number is 204 091 484B
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201105 BCH - 130998 1 BL- 2

Job Capacity Assessment Report
JSKID - 15443080, Submitted Date - 22/10/2020
Client Details
Job seeker ID: 15443080 CRN: 204091484B
Name: MR DAVID WEBB
Date of birth: 15/02/1960 Gender: Male
Referral Details
Date of referral: 16/10/2020
Reason for assessment: DSP New Claim
Referring organisation: Centrelink
Assessment Format requested: Face To Face
Referring officer:
Referring on behalf of: Centrelink ASSESSMENT SERV
Phone: 1800110608
Assessment Details
Provider: Centrelink TAREE
Phone: 18 00110608
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Assessor's name:
Professional discipline:
Registered Occupational Therapist

JCA Assessor
Location: Services Australia, Centrelink Taree Service Centre
Assessment Dates: 19/10/2020
Form of assessment: Telephone

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Page 1 of 11
Was an interpreter used for the assessment?: No
Interpreter details:
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Client has been advised of information sharing arrangements: Yes
Medical Conditions
Medical Condition Details
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Condition: Shoulder and Upper Arm Type: Permanent

Disorder
This condition is: Verified by medical evidence; Fully Diagnosed.
Remarks:
The Northwest Private Hospital Nursing Discharge Summary - Admitted Patient, dated 25/07/2020 and reports by
Orthopaedic Surgeon, Dr Tack-Shin Lee dated 19/02/2020, 4/03/2020 advises of the following:
Diagnosis: Complete Tear of the Right Rotator Cuff Tendon (Right Reverse Total Shoulder Replacement)
Date of Onset/Diagnosis: November 2019
Treatment: Right shoulder total replacement arthroplasty, performed on 23/07/2020. Dr Lee (4/03/2020) reports
"patient is to wear a sling for 6 weeks after the surgery. There is a need for revision surgery in future. Patient is to
avoid heavy loading of the right arm." The client reported that he underwent right shoulder surgery 3 months ago
and that he saw his surgeon Dr Lee last week and that Dr Lee gave him exercises to do and recommended a 3-5kg
weight limit using his right upper limb.
Symptoms/Impacts: Dr Lee (4/03/2020) reports (pre surgery) symptoms consisting of right shoulder pain, right
shoulder forward flexion of 100 degrees, external rotation is 20 degrees, with interneal rotation of the right
shoulder, patient can only place right hand beside right buttock. The client reported that he is still recovering from
shoulder surgery.
Prognosis and FDTS (fully diagnosed, treated and stabilised rationale): For the purposes of this assessment, this
condition is considered to be permanent and fully diagnosed, but not fully treated and stabilised for the following
reasons: The client is currently recovering from recent surgery and further treatment (i.e. shoulder exercises,
specialist followup) with the prospect of likely improvement in the client's condition has been
recommended/initiated but has not as yet been undertaken/completed. Given these factors this condition cannot
currently be considered to be fully treated and stabilised.
References Used:
Reference ID Dated From Source
Page 2 of 11
4574236 11/07/2020 Report Treating Health Professional

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Condition: Intervertebral Disc Disorder Type: Permanent

This condition is: Verified by medical evidence; Fully Diagnosed; Fully Stabilised.
Remarks:
The Health Summary Sheet dated 11/07/2020 completed by GP, Dr Patrick Chew and Operation Report by
Neurosurgeon & Spinal Surgeon, Dr Andrew Kam, dated 9/02/2015 advises of the following:
Diagnosis: Dr Chew (11/07/2020) reports L4/5 Discitis with the onset in 2014, Dr Kam (9/02/2015) reports
Mechanical lower back pain post osteomyelitis and discitis L4/5.
Date of Onset/Diagnosis: 2014
Treatment: Dr Chew reports L2 to S1 fusion in 2015, Dr Kam (9/02/2015) reports treatment consisting of surgery
(Midline L3-5 laminectomy and bilateral L3-S1 MIS fixation with cement augmentation. The client reported
treatment consisting of surgery in 2015 (spinal fusion and laminectomy in 2015, followed by 6 months physiotherapy
at Westmead hospital. The client reported no other treatment for this condition.
Symptoms/Impacts: Dr Kam (9/02/2015) reports symptoms (pre surgery) of mechanical back pain which is usually
made worse when he is in the vertical position whether sitting or standing. The client reported symptoms consisting
of lower back pain and that as a result of the spinal surgery he experienced nerve damage affecting his legs/mobility.
The client reported that he experiences a "floppy right foot."
condition cannot currently be considered to be fully treated and stabilised as the medical evidence advises of
treatment consisting of spinal surgery in 2015 only, there is no medical evidence to advise that the client has
undertaken a program of care to comprehensively, and optimally manage this condition. Given these factors this
condition cannot currently be considered to be fully treated.
References Used:

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Condition: Diabetes - Non Insulin Type: Permanent

Dependent
Page 3 of 11
Remarks:
The Health Summary Sheet, by GP, Dr Patrick Chew dated 11/07/2020 listst the medical condition Diabetes, with
treatment reported as Diabex tablet 500mg at night. There is a GP Management Plan, dated 28/08/2020, that
includes treatment strategies for this condition, however there is insufficient medical information provided to
confirm that these strategies have been undertaken/completed. Given these factors, this condition cannot currently
be considered to be fully treated and stabilised.
References Used:

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Condition: Skin Disorder-Other Type: Permanent

This condition is: Verified by medical evidence.
Remarks:
The Health Summary Sheet, by GP, Dr Patrick Chew dated 11/07/2020 lists the medical condition recurrent leg
ulcerations. There is insufficient medical information supplied in the medical evidence in order to properly
determine if this condition has been fully diagnosed, treated and stabilised.
References Used:

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Condition: Lower Limb Deficiencies Type: Permanent

This condition is: Verified by medical evidence; Fully Diagnosed; Fully Treated.
Remarks:
The reports by Orthopaedic Surgeon, Dr Tack-Shin Lee dated 19/02/2020 advises of the following:
Diagnosis: Total Right Knee Replacement.
Date of Onset/Diagnosis: 2019
Treatment: Dr Lee (19/02/2020) reports that treatment has consisted of a total right knee replacement on
8/08/2019. The client reported 2 weeks rehabilitation following surgery and no current treatment.
Symptoms/Impacts: Dr Lee (19/02/2020) reports "he is now six months following his surgery. He is very happy with
the outcome of his surgery. He still walks with the help of one wal;king stick, However, he has no pain in the right
knee. The right knee has 0 to 110 degrees range of motion. The wound has been well healed. X -ray of the right knee
from 19 February 2020 shows good fixation and good alignment. The client reported that the right total knee
replacement surgery was successful, although he still experiences restricted movement and pain in his right knee.
Page 4 of 11
The client reported that this condition is continuing to improve slowly with lessening knee pain over time.
condition is considered to be fully diagnosed and treated, however, this condition cannot currently be consiodered
to be stabilised as the client reported ongoing improvement in symptoms and it appears likely that some
improvement in functional capacity may occur within the next two years.
References Used:

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Condition: Musculo-skeletal Disorder - Type: Permanent

Other
This condition is: Verified by medical evidence.
Remarks:
The report by Orthopaedic Surgeon, Dr Tack-Shin Lee dated 10/07/2019, lists Past Medical History including a Left
total hip replacement in 2001. No further medical information is supplied regarding this conditon. The client
reported that his left hip was replaced 20 years ago and is currently painful and "worn out" The client reported that
his GP has advised that he will need another hip replacement in future. There is insufficient medical information
supplied in the available medical evidence in order to effectively confirm that this condition has been fully
diagnosed, treated and stabilised.
References Used:

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Condition: Morbid Obesity Type: Permanent

Remarks:
The report by Orthopaedic Surgeon, Dr Tack-Shin Lee dated 10/07/2019, lists Past Medical History including Obesity.
There is a GP Management Plan, dated 28/08/2020, that includes treatment strategies (i.e. nutrition, physical
activity, weight etc) to address this condition, however there is insufficient medical information provided to confirm
that these strategies have been undertaken/completed. Given these factors, this condition cannot currently be
considered to be fully treated and stabilised.
Page 5 of 11
References Used:

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Condition: Myopathy -Other Type: Permanent

Remarks:
The report by Orthopaedic Surgeon, Dr Tack-Shin Lee dated 10/07/2019, lists Past Medical History including Atrial
Fibrilation, which was diagnosed 4 years ago. There is a GP Management Plan, dated 28/08/2020, that includes
treatment strategies for Stent - Coronary Artery which include controlling risk factors, medication and regular
reviews with Cardiologist. However there is insufficient medical information provided to confirm that these
strategies have been undertaken/completed. Given these factors, this condition cannot currently be considered to
be fully treated and stabilised.
References Used:

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The client's medical condition/s does not prevent them from using public transport without substantial assistance.
References
Information/evidence considered in preparation of this assessment included but was not limited to the following:
Reference ID: 4574236 Dated: 11/07/2020
Form: Report Source: Treating Health Professional
Author: DR Patrick Chew
Field: GP/Treating Doctor

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Page 6 of 11
Author: DR Patrick (GP Mgt Plan) Chew
Field: GP/Treating Doctor

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Author: DR Hyunmin Park
Field: Neurologist
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Author: DR Tack-Shin Lee
Field: Orthopaedic Specialist

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Page 7 of 11
Author: DR Andrew Kam
Impairment
No Impairments have been recorded.
Barriers
Barriers to be addressed
Barrier: Limited work goals (V04)
Barrier: Chronic pain (H12)
Barrier: Endurance limitations (H07)
Barrier: Limited physical abilities (H01)
Barrier: Mobility restrictions (H11)
Support Requirements
Requirement: Cope with work related stress and pressure Duration: 12 to 24 months
Requirement: Physically complete work tasks Duration: 12 to 24 months
Requirement: Move around safely Duration: 12 to 24 months
Requirement: Build work capacity Duration: 12 to 24 months
Requirement: Maintain sustainable employment Duration: 12 to 24 months
Work Capacity
Baseline Work Capacity: 8-14 Hours per week
Page 8 of 11
(Excludes any temporary impacts noted above)
Suitable Work: Light less skilled (W03)

Examples:
Clerical work
Capacity for work within 2 years with Intervention Work Capacity: 15-22 Hours per week
Suitable Work: Light less skilled (W03)

Examples:
Clerical work
Temporary Work Capacity: 0-7 Hours per week
End Date: 31/03/2021
The customer's FDTS work capacities are 30+ hours per week, as the customer does not have any permanent, fully
diagnosed, treated and stabilised medical conditions.
Rationale:
The client is currently experiencing medical conditions which limit work capacity to 0-7 hours per week until the date
specified above, as these medical conditions may improve with continued/additional treatment. This will allow time
for the client to undertake further recommended investigations/assessments and treatments and improve their
ability to effectively participate in a program of support.
Baseline work capacity is reduced due to the impacts of the client's permanent health conditions, resulting in chronic
pain, joint stiffness, weakness and fatigue resulting in reduced physical capacity and endurance to sustain work
related tasks, reduced capacity to cope with work related pressure, and reduced ability to maintain work routines
and reliability. Given these limitations a baseline work capacity of 8-14 hours per week is recommended.
The client's with intervention work capacity is expected to be 15-22 hours per week. Interventions such as disability
management/treatment, adjustment to disability counselling/support, vocational assessment/counselling, job
matching, workplace assessment/modification, work hardening and on the job support is likely to assist the client to
achieve and sustain this work capacity within 24 months.
Interventions
Interventions that were identified for this client
Intervention: Disability management education/counselling (H59)
Page 9 of 11
Intervention: Driving/mobility assessment/assistance (U53)
Intervention: Functional capacity evaluation/assessment (H55)
Intervention: Job matching (V54)
Intervention: Pain management program (M55)
Intervention: Vocational assessment/counselling (V52)
Intervention: Vocational rehabilitation (V51)
Intervention: Workplace assessment (V55)
Intervention: Workplace modifications (V62)
Assessment Summary
The assessment was completed successfully.
Employment History / Goals:
The client reported that he completed school to Year 10 and post school training/qualifications including completion
of an auto mechanics trade certificate and post trade automatic transmission courses. The client reported a work
history consisting of working as a notor mechanic and auto transmission mechanic all his working life. The client
reported that his most recent job was working in his own automatic transmission business, up until about march
2019, when he reported that he closed his business as he was no longer able to manage the physical demands of this
work due to the impacts of his medical conditions.
Employment Goal/s: The client reported that he did not currently feel capable of working in any capacity due to the
combined impacts of his health conditions.
Barriers & Interventions summary:
See barriers and interventions
Additional Comments:
A deferred referral to DES - DMS, (i.e. to be actioned by Centrelink after 31/03/21 please) is recommended, The
referral has not been activated, as the client was applying for DSP. Pending the outcome of DSP application, if
required, Services Australia may activate the referral recommendations outlined in the report.
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This report does not contain any information, which if released to the client, might be prejudicial to his/her health.
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Page 10 of 11
The client's personal factors have Low impact on their ability to work, obtain work or look for work.
Rationale:
See barriers
Referrals
Recommendation Type Program / Other Program Timeframes / Dates
Employment Service DES - Disability Management Service
Confidentiality and Privacy

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required by the Privacy Act 1988 or other Commonwealth legislation, or where you have provided your consent. For
more information about privacy and the way in which your personal information is managed you can talk to your
Employment Service Provider, the Department of Education, Skills and Employment, the Department of Human
Services, Centrelink or the Privacy Commissioner (who can be contacted through www.privacy.gov.au).
Page 11 of 11

LEX 60445 - Decision - Final Documents

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LEX 60445 - Administrative Release - Page 2 of 15

Your reference number is 204 091 484B

If you do not agree with a decision we have made

All of the above are free of charge.

If you do not agree with a decision we have made, contact us as soon

Privacy and your personal information

To make a complaint or give us feedback

If we are not able to resolve your complaint to your satisfaction, you

201105 BCH - 130998 1 BL- 2

JSKID - 15443080, Submitted Date - 22/10/2020

Name: MR DAVID WEBB

Date of birth: 15/02/1960 Gender: Male

Reason for assessment: DSP New Claim

Referring organisation: Centrelink

Assessment Format requested: Face To Face

Referring on behalf of: Centrelink ASSESSMENT SERV

Registered Occupational Therapist

Location: Services Australia, Centrelink Taree Service Centre

Assessment Dates: 19/10/2020

Form of assessment: Telephone

JSKID - 15443080, Submitted Date - 22/10/2020

Was an interpreter used for the assessment?: No

Client has been advised of information sharing arrangements: Yes

Condition: Shoulder and Upper Arm Type: Permanent

Reference ID Dated From Source

JSKID - 15443080, Submitted Date - 22/10/2020

4574236 11/07/2020 Report Treating Health Professional

4574242 19/02/2020 Report Treating Health Professional

4574246 04/03/2020 Report Treating Health Professional

4574248 10/07/2019 Report Treating Health Professional

Condition: Intervertebral Disc Disorder Type: Permanent

Reference ID Dated From Source

4574236 11/07/2020 Report Treating Health Professional

4574266 09/02/2015 Report Treating Health Professional

Condition: Diabetes - Non Insulin Type: Permanent

JSKID - 15443080, Submitted Date - 22/10/2020

Reference ID Dated From Source

4574236 11/07/2020 Report Treating Health Professional

4574238 20/08/2020 Report Treating Health Professional

Condition: Skin Disorder-Other Type: Permanent

Reference ID Dated From Source

4574236 11/07/2020 Report Treating Health Professional

Condition: Lower Limb Deficiencies Type: Permanent

JSKID - 15443080, Submitted Date - 22/10/2020

Reference ID Dated From Source

4574242 19/02/2020 Report Treating Health Professional

4574246 04/03/2020 Report Treating Health Professional

4574248 10/07/2019 Report Treating Health Professional

Condition: Musculo-skeletal Disorder - Type: Permanent

Reference ID Dated From Source

4574248 10/07/2019 Report Treating Health Professional

Condition: Morbid Obesity Type: Permanent

JSKID - 15443080, Submitted Date - 22/10/2020

Reference ID Dated From Source

4574238 20/08/2020 Report Treating Health Professional

4574248 10/07/2019 Report Treating Health Professional

Condition: Myopathy -Other Type: Permanent

Reference ID Dated From Source

4574236 11/07/2020 Report Treating Health Professional

4574238 20/08/2020 Report Treating Health Professional

Reference ID: 4574236 Dated: 11/07/2020

Form: Report Source: Treating Health Professional

Author: DR Patrick Chew

Field: GP/Treating Doctor