Workers’ Compensation Follow-up/Return-to-Work Progress Note

Date of Service: [Date of service]

Clinician: [Clinician name, credentials]

Claim Number: [Claim number] (Include if known; use "Unknown" only if operationally required and not available.)

Date of Injury (DOI): [Date of injury]

Body Part(s)/Condition(s): [Involved body part(s) and work-related diagnosis(es)]

Job Title: [Job title]

Current Work Status: [off work / modified duty / full duty]

Reason for Visit

[One- to two-line statement of follow-up purpose framed around progress and work capacity]

Interval History

[Symptom trajectory since last visit] (Briefly summarize course using time anchors; include better/same/worse, variability, and notable triggers/relievers.)

[Functional status in work-relevant terms] (Describe tolerances for standing, walking, lifting, carrying, reaching, gripping, or other job-specific functions; note what the patient can and cannot do. Use concise quotes for key functional concerns when they clarify.)

[Work status since last visit] (State off work/modified/full duty; tolerance of current duties; any lost time; issues encountered on the job.)

[Treatments and response] (Summarize adherence and response to therapy, medications, procedures, bracing/ergonomics. Note perceived benefit and barriers.)

[Interim diagnostics or outside records reviewed] (Brief synthesis of pertinent findings only.)

[Psychosocial or workplace factors affecting RTW] (Document barriers or facilitators such as fear-avoidance, job availability, transitional duty options. Label as patient-reported versus clinician observations.)

(Omit any category above if no information was obtained.)

Objective

[Focused physical examination findings tailored to the injury] (Emphasize measurable, reproducible findings—ROM with degrees, strength grading, girth measurements, neurologic testing, special tests with named results. Compare to prior visit when helpful. Include relevant imaging/study results with dates. Include vitals only when clinically relevant.)

(When the patient is not at full duty, explicitly document objective medical findings supporting the restrictions. Clearly separate objective findings from subjective symptoms. If no examination was performed, briefly state the reason and omit the rest of this section.)

Assessment

[Problem-oriented assessment of each active work-related condition] (For each problem, state diagnosis, current status as improving/stable/worsening, and brief clinical reasoning linking findings to functional impact. Note complicating factors or barriers when present. Address work-relatedness/causation or MMI only if newly established, disputed, or required by workflow—otherwise omit.)

Plan

[Problem-oriented treatment plan] (For each problem, include relevant elements: therapy continuation or changes, medications, procedures, activity progression, diagnostics ordered with brief rationale, referrals or coordination needs, patient education points. State follow-up interval tied to expected clinical change.)

Work Status & Restrictions

(This section should stand alone as an actionable summary for employers and claims administrators.)

Work Status: [full duty / modified duty / off work], effective [date], reassess by [date or timeframe]

Restrictions: [Specific, measurable restrictions with quantified limits—e.g., weight limits, postural limits, tolerance durations, equipment requirements; state whether restrictions apply at work only or to all activities] (When full duty, state: "Released to full duty with no restrictions.")

Capabilities: [Brief positive statement of what the patient can safely do to facilitate job matching]

RTW Plan: [Expected progression of restrictions, criteria for advancement, and whether job description review, transitional duty, or work conditioning is recommended]

Medical Rationale: [One to two sentences linking restrictions to documented objective findings or demonstrated functional limits]

(Omit any field that cannot be completed, except Work Status which must always be addressed.)