Occupational Medicine Visit Note (Work-Related Injury/Illness)

Date/Time: [Encounter date and time]

Visit Type: [Initial / Follow-up / Closing]

Patient: [Full name and identifier]

Treating Clinician: [Name, credentials]

Employer: [Employer name]

Date of Injury/Exposure: [Date (and time if known)]

Claim Number: [Claim number] (Include only if known; omit entire line if not applicable.)

Chief Complaint

[One-line statement of the primary reason for visit including body part/system and relation to work] (Keep to a single concise sentence.)

History

[Interval history since last visit] (For follow-up visits only: Summarize response to treatment, symptom changes, adherence, new evaluations, and any work status changes since the prior visit. Place this paragraph first on follow-ups; omit entirely on initial visits.)

[Patient-reported mechanism of injury or exposure, with date/time, task being performed, body position, equipment/agents involved] (Include route of exposure when relevant, duration/intensity, and immediate first aid or decontamination. Include one brief verbatim quote in quotation marks when it clarifies the mechanism.)

[If mechanism of injury or date of injury cannot be obtained, explicitly state: Unable to obtain mechanism and/or date of injury because [reason].] (Use this statement only when details cannot be obtained; do not omit silently.)

[Symptom timeline and characteristics] (Summarize onset, progression, frequency, location, severity, quality, aggravating/relieving factors, associated symptoms including neurologic symptoms, and red flags if present.)

[Functional impact] (Describe effects on specific work tasks and activities of daily living. Reference concrete tasks the patient can and cannot perform.)

Relevant Job Demands: [Physical and environmental demands pertinent to restrictions] (Include when relevant to restriction decisions: lifting/carrying, postural demands, repetitive tasks, driving/machinery operation, environmental exposures. Quantify when possible.)

Prior Care: [Prior evaluations and treatments for this condition and responses] (Include medications, procedures, therapy, imaging, and outcomes. Note adverse effects or barriers.)

Pertinent Past History: [Prior injuries, surgeries, or conditions involving the same body region; relevant comorbidities affecting recovery] (Include only if relevant; omit if none.)

Medications: [Current medications with dosages if provided] (Flag sedating medications relevant to work and driving safety.)

Allergies: [Allergies and reactions]

Objective

Vitals: [Vitals obtained] (Include only if measured during this encounter; omit line if not obtained.)

Exam: [Findings by body region] (Document only what was actually assessed; do not auto-populate normal findings. For each region examined, include pertinent inspection, palpation, range of motion with measurements, strength with grades, neurovascular status, and provocative tests with results as applicable.)

[Exam limitations] (State if exam was limited by splint/cast, pain, wound, or telehealth constraints, and specify what could not be assessed. Omit if no limitations.)

Diagnostics: [Completed imaging, labs, and test results with dates and source] (If personally interpreting an image, state your impression and whether the final radiology read is pending. Include only completed tests; do not list planned or pending studies here.)

Assessment

(List problems in problem-oriented format. Include ICD-10 codes when used. For each problem, briefly state supporting rationale from history and exam.)

[Problem 1]: [Diagnosis/clinical impression] [ICD-10 code]

• [Supporting rationale linking key history and exam findings]
• Work-relatedness: [Clinically consistent with reported work event / Indeterminate pending additional records or diagnostics / More consistent with non-occupational etiology] — [Brief rationale] (If determination cannot be made, explicitly state what is needed and why.)

[Problem 2]: [Diagnosis/clinical impression] [ICD-10 code]

• [Supporting rationale]
• Work-relatedness: [Statement and rationale]

(Add additional problems as needed; omit if only one problem.)

Plan

(Organize by problem when multiple issues exist.)

[Problem 1]

• Treatment provided today: [Procedures, splinting/immobilization, wound care, injections]
• Medications: [Medication name, dose, route, frequency, duration] (Include explicit cautions for sedating medications regarding machinery operation, driving, and fall risk.)
• Therapy: [Type, frequency, duration, and functional goals]
• Diagnostics ordered: [Studies ordered with rationale]
• Referrals: [Specialty and specific clinical question]
• Patient education: [Key counseling points, home program, ergonomic or PPE guidance]
• Follow-up: [Interval for re-evaluation and red flags prompting earlier return]
• Authorization needed: [Item requiring authorization and medical necessity rationale] (Include only if authorization is required.)

(Include only applicable items above; omit bullets that do not apply. Add additional problem sections as needed.)

Work Status

Status: [Off work through (date) / Modified duty effective (date) / Full duty effective (date)] (Choose one and provide the effective or through date.)

Restrictions: [Quantified functional limitations by category] (List only applicable categories. Include specific limits for: lifting/carrying weight and frequency, pushing/pulling, standing/walking duration, sitting duration, bending/twisting, overhead reaching with laterality, repetitive hand use with laterality, climbing, driving/machinery operation, and environmental restrictions. Avoid vague terms like "light duty" or "as tolerated" without quantified limits.)

Duration: [Expected duration of restrictions] — Next review: [date]. [Objective milestones for progression if applicable]

[Changes from prior visit and clinical basis] (Include only if restrictions changed from the prior visit; state what changed and why.)

— [Clinician signature, credentials] — [Date/Time]

[Supervising clinician attestation] (Include only if trainee supervision or co-signature required.)

[Scribe statement] (Include only if scribe was used.)