BC Persons with Disabilities (PWD) Medical Report

Who may complete the medical report

• Physicians and nurse practitioners in a position to speak to the impairment.
• Other regulated professionals only if the current form names them for that section.
• If you took over care last month and the chart is thin, say how long you have known the person and what you verified versus what you were told.

How to complete the clinical sections

Start with the impairment that actually restricts daily living, not the longest problem list. Schizophrenia with disorganization that stops the person managing medications, food, and appointments is a PWD story. 'Has anxiety' is not.

• Name the diagnoses you can support and the year they began, as best the chart allows.
• State whether the impairment is severe and whether it has lasted, or is likely to last, two years or more.
• Describe daily living: personal care, meal prep, medications, mobility in the home, community access, social communication. Use examples from this patient.
• Help needed: another person, frequent prompts, or assistive devices — and how often.
• Treatment and residual restriction. If medication controls the impairment so daily living is not significantly restricted, write the residual, not the untreated worst day.
• Prognosis: likely ongoing, fluctuating, or expected to improve inside two years. Guessing 'permanent' without a basis helps no one.

Worked example (fictional)

Conditions: schizophrenia, continuous; mild intellectual disability. Followed here since 2019. Last hospital admission 2024.
Impairment: severe, ongoing, expected to last well beyond 2 years.
Daily living:
- Cannot independently manage a weekly pill organizer; sister fills it and phones daily. Two relapses in 5 years when she was away.
- Does not initiate meals; uses prepared food only if left in the fridge and prompted. Lost 6 kg during a 3-week period without that support.
- Cannot use transit to new locations; becomes overwhelmed and returns home. Attends the mental-health team only with a ride and an escort.
- Hygiene needs twice-weekly prompts; would not bathe unprompted.
Treatment: paliperidone palmitate, case management, sister as informal caregiver. Restriction remains significant on treatment.
I am the most responsible NP and have seen this patient 11 times in 2 years.

Why the ministry sends the file back

• Diagnosis without daily-living examples.
• Checking every box weakly instead of describing the real restriction.
• Duration left blank, or 'unknown' when the chart shows years of the same impairment.
• Writing as if PWD were T2201 or a work-capacity form.
• Illegible handwriting or a missing practitioner identifier.

Frequently asked questions