Return-to-Work Clearance Exam Note

Encounter Details

Encounter Date/Time: [date and time]

Clinician: [name, credentials, contact]

Exam Type: [Treating clinician RTW evaluation / Occupational health fitness-for-duty / Independent evaluation]

Referral Source: [self / employer / HR / workers' comp / other]

Employer: [employer name and worksite, or "Not provided"]

Job Title: [title, department, shift pattern if relevant]

Workers' Comp Claim #: [claim number and date of injury] (Include only if work-related injury; otherwise omit entirely.)

Reason for Evaluation

[Purpose of return-to-work clearance and specific determination requested] (1–3 sentences stating the condition/injury context and whether clearance is for full duty, modified duty, safety-sensitive clearance, or restriction duration review.)

Information Reviewed

• [Patient history obtained today]
• [Prior medical records reviewed with dates]
• [Imaging and/or laboratory results reviewed]
• [Operative or procedure reports reviewed]
• [Job description or job demands documentation reviewed with date/source]
• [Functional Capacity Evaluation findings] (Include only if performed or available.)
• [Key records unavailable] (If applicable, note that assessment is based on patient report and today's exam.)

Job Demands and Essential Functions

(Document job requirements relevant to the clearance decision. If employer documentation is unavailable, label as patient-reported and note clearance may be conditional pending employer verification.)

• Role and primary tasks: [job title and essential functions] — Source: [employer-verified / patient-reported]
• Physical demands:
  • [Lifting/carrying: maximum weights and frequency (occasional/frequent/constant)]
  • [Push/pull forces and frequency]
  • [Standing/walking duration per shift]
  • [Sitting duration and breaks]
  • [Climbing (stairs/ladders), heights exposure]
  • [Kneeling/crouching/crawling/bending frequency]
  • [Overhead work or reaching requirements]
  • [Repetitive motions and pace requirements]
  • [Grip/pinch strength demands or tool use]
  • [Driving requirements: type, duration, conditions]
• Cognitive/environmental demands: [sustained attention, heat/cold exposure, respirator use, vibration, shift work, solo/remote work] (Include only if relevant to condition.)
• Safety-sensitive task screening: [commercial/occupational driving / heavy machinery operation / work at heights / firearms or security duties / hazardous energy control (LOTO) / patient care or public safety responsibilities / solo or remote work] (List those that apply; if none, state "No safety-sensitive tasks identified.")

Clinical History

[Interval history of illness/injury] (Include onset and mechanism, treatment course—medications, PT/OT, procedures/surgery—current symptom status and severity, functional limitations at home and any work simulation attempted, current work status, and date last worked.)

[Relevant past history affecting capacity or safety] (Prior similar injuries, conditions affecting endurance/mobility/cognition, seizure/syncope history. Omit if none relevant.)

[Medications relevant to safety-sensitive work] (List current medications with sedation, cognitive, dizziness, or hypoglycemia risk and patient-reported side effects relative to work hours. Include only for safety-sensitive roles or if otherwise relevant.)

[Focused review of systems] (Limit to systems pertinent to the clearance question.)

Examination

• Vital signs: [relevant vitals] (Include when relevant to exertional capacity or safety.)
• General/observation: [gait, posture, use of assistive devices]
• Musculoskeletal: [findings with quantified ROM, strength grading, tenderness, swelling, stability, special tests as applicable]
• Neurological: [sensation, reflexes, coordination, balance, cognitive status as relevant]
• Cardiopulmonary: [findings as indicated by condition and job demands]
• Other systems: [findings] (Only if relevant.)
• Functional testing: [results of timed sit-to-stand, grip strength, lift/carry assessment, walk test, or work simulation tasks performed today]
• FCE summary: [key objective capacity findings from FCE] (Include only if FCE was reviewed.)

Job Demand vs Capacity Analysis

(Match each relevant essential function to patient's demonstrated capacity. Use objective data from today's exam/testing and reviewed records.)

• [Essential function #1]

  • Job requirement: [quantified demand]
  • Patient's current capacity: [measured ability and source]
  • Gap: [none / present]
  • Restriction needed: [specific, measurable restriction or "none"]

• [Essential function #2]

  • Job requirement: [quantified demand]
  • Patient's current capacity: [measured ability and source]
  • Gap: [none / present]
  • Restriction needed: [specific, measurable restriction or "none"]
• (Add additional essential functions as needed.)

Safety-sensitive considerations: (Include only if safety-sensitive tasks are involved.)

• Alertness/cognitive reliability: [adequate / concerns with explanation]
• Dizziness/syncope/seizure risk: [risk assessment and clearance implications]
• Medication impairment risk: [medications of concern and timing relative to work]
• Sudden incapacitation potential: [assessed risk and acceptability for safety-sensitive tasks]

Assessment

• [Diagnosis or working diagnosis]: [improving / stable / worsening] — [functional impact summary tied to job demands]
• [Secondary diagnoses if relevant]: [status] — [functional implications]
• Uncertainty or information gaps: [additional information, records, or testing needed to clarify capacity] (Omit if none.)

Work Status Determination

(This section is always required and must be unambiguous. Format to allow extraction as a standalone work note.)

Duty Status: [Cleared for full duty / Cleared with restrictions / Not cleared to work / Cleared except for safety-sensitive tasks / Decision deferred pending (specify)]

Effective Date: [start date of clearance or restrictions]

Duration/Re-evaluation: [end date for restrictions or next evaluation date] (If permanent, state "permanent" with justification.)

Restrictions: (List each as specific, measurable limits. Avoid vague terms like "light duty" or "as tolerated" without quantification. Omit if cleared for full duty.)

• [Lifting/carrying limit: maximum weight and frequency] — Duration: [duration or "see above"]
• [Push/pull force limit with frequency] — Duration: [duration]
• [Standing/walking duration limits] — Duration: [duration]
• [Sitting duration and break requirements] — Duration: [duration]
• [Postural restrictions: no ladders / no kneeling / limit bending] — Duration: [duration]
• [Overhead work/reaching restrictions] — Duration: [duration]
• [Driving restrictions] — Duration: [duration]
• [Environmental restrictions] — Duration: [duration]
• [Safety-sensitive task restrictions] — Duration: [duration]

Rationale: (1–3 bullets connecting restrictions to objective findings.)

• [Objective finding] → [functional/safety implication] → [corresponding restriction]

Accommodation Suggestions: (Recommendations for employer consideration; omit if none needed.)

• [Potential accommodation]

Plan

• Treatment: [ongoing treatment—PT/OT, home exercise, medications with impairment warnings, procedures, referrals]
• Follow-up: [timing and objective milestones to advance work status]
• Criteria for clearance: [specify what must be met to reconsider clearance] (Include if not cleared or if restrictions are time-limited.)

Documentation Provided

• [Work note/restrictions form provided to patient with effective dates]
• [Information sent to employer or third party: what disclosed, to whom, date, and authorization basis]
• [Diagnosis disclosure status] (If employer requested diagnosis and patient did not authorize, note "Diagnosis disclosure declined per policy.")

(Omit this section entirely if no work note was generated and no third-party communication occurred. Do not include diagnosis on employer-facing communications unless patient explicitly authorizes. If job demands were patient-reported, flag clearance as conditional pending employer verification.)