Occupational Medicine Clinic SOAP Note

Date/Time: [Encounter date and time]

Patient: [Patient name and identifiers]

Provider: [Provider name and credentials]

Visit Type: [work injury initial / work injury follow-up / exposure evaluation / return-to-work clearance / other]

Employer/Worksite: [Employer name / Unknown / N/A]

Job Title: [Job title / Unknown / N/A]

Claim Type: [Workers' Compensation / Employer direct / N/A]

Claim Number: [Claim number / Unknown / N/A]

Date of Injury/Exposure: [Date / Unknown / N/A]

Subjective

Chief Complaint: [Chief complaint in patient's own words with visit intent]

History: [Narrative history of injury/exposure including mechanism, chronology, progression, prior treatment and response, and prior injuries to same body region] (For exposures, include agent, route, duration, PPE used, and whether coworkers affected. Attribute information sources: patient report vs. records vs. employer.)

Job Demands: [Relevant physical and environmental demands of job] (Note if based on formal job description or patient estimate.)

Functional Impact: [Current functional limitations compared to baseline, including affected work tasks and ADLs]

Relevant History: [Pertinent PMH, PSH, medications, allergies] (Include only if relevant to the complaint, treatment, or safety-sensitive work. Omit section if not pertinent.)

Objective

Vitals: [Vital signs as clinically relevant]

Exam: [Focused physical examination findings] (Document pertinent positives and negatives. Include inspection, palpation, ROM with values, strength grades, sensation, and relevant provocative tests. Specify laterality and note any pain inhibition or effort concerns.)

Data: [Imaging, labs, and external records reviewed with key findings] (Note pending studies and interim restriction management while awaiting results.)

Assessment

Diagnoses: [Problem list ordered by severity and work impact] (Separate work-related conditions from non-work-related conditions affecting recovery.)

Work-Relatedness: [For each relevant condition: determination and rationale] (State work-related, work-aggravated, undetermined, or not work-related with brief rationale based on temporal relationship, mechanism plausibility, and objective findings. If uncertain, label provisional and note additional information needed.)

Functional Status: [Summary of current work capacity with key limiting findings tied to job demands]

Plan

Treatment: [Medications with safety counseling if applicable, non-pharmacologic care, therapy referrals with functional goals, procedures performed]

Diagnostics: [Pending imaging, labs, referrals with indication] (For exposures, include SDS retrieval or worksite evaluation plan if needed.)

Work Status: [Full duty / Modified duty / No work] — Effective [date] through [expiration or review date]. Next follow-up: [date or interval]. (Omit if no work capacity decision made.)

Restrictions: [Functional, measurable limits] (If modified duty: specify weight limits with frequency, postural limits, sit/stand tolerances, driving/machinery limits, environmental limits, and progression plan. Omit if full duty or no work.)

Patient Education: [Expected recovery course and warning signs]

Coordination: [Communications with employer, adjuster, or case manager] (Include date, method, and content. Omit if none.)

Work Status Summary

(Standalone summary for employer/insurer. Omit diagnoses; focus on functional limits only. Include only if work capacity decision is being made.)

Worker: [Worker name]

Employer: [Employer / Unknown]

Job Title: [Job title / Unknown]

Date of Injury/Exposure: [Date / Unknown / N/A]

Work Status: [Full duty / Modified duty / No work]

Restrictions: [Bulleted, measurable functional restrictions]

Effective: [Date] — Review/Expires: [Date]

Next Appointment: [Date or interval / TBD]

Provider Signature: ____________________ [Provider name, credentials]