RTW Note

[comment memo="All dates must be entered as mm-dd-yyyy, if you do not use the drop down calendar. mm/dd/yyyy format will not work. If you don't want to enter dates, leave the field blank and nothing will populate."]
SUBJECTIVE:
[select name="variable_1" value="Mr.|Mrs.|Ms."] [text name="variable_2" default=" "] presents to return to work.
1. Last Day Worked: [date name="variable_3" default=" "]
2. First Date of Disability/Date Sick Leave Started: [date name="Variable_4" default=" "]
3. Return to work date: [date name="variable_5" default=" "]
4. Attending provider: [text name="variable_6" default=" "]
5. Type of absence: [select name="variable_7" value="Occupational(work related)|Non-occupational"]
6. Medical Diagnosis: [text name="variable_8" default=" "]
7. Hospitalized: [select name="variable_9" value="No|Yes"]
8. Surgery: [select name="variable_10" value="No|Yes"]
9. Restrictions: [select name="variable_11" value="No|Yes:"] [text name="variable_12" default=" "] [comment memo="If yes, list restrictions"]
10. Provider's written RTW note: [select name="variable_13" value="Yes|No"]
11. Dates coincide with sick leave: [select name="variable_14" value="Yes|No"]
12. Shift: [select name="variable_15" value="1st|2nd|3rd"] Department:[select name="variable_16" value="17-Trim|25-Chassis|15-Paint|45-Paint|10-Stamping|12-Stamping|42-Stamping|11-Body Shop|43-Body Shop|45-Skilled Trades|47-Skilled Trades|50-Material|70-Quality|40-Central Engineering|48-Central Engineering|44-Power House|75-Engineering|80-Salaried Personnel|81-Health Services|85-UAW Administration|Other"] Supervisor:[text name="variable_17" default=" "]
15. Sign-in Date: [date name="variable_18" default=" "]

OBJECTIVE:
General: A&O x3. Calm, pleasant and cooperative. No objective/obvious signs of disability noted.
Musculoskeletal: Ambulated to clinic.

ASSESSMENT:
1. [text name="variable_19" default=" "]

PLAN:
1. Employee returned to work [select name="variable_20" value="full duty.|with the above noted restrictions."]
2. RTW 1/2 completed. Copy provided to labor and employee provided 2 copies, 1 for self and 1 for supervisor.
3. RTW note from provider scanned into the EMR.
4. RTC [select name="variable_21" value="as needed.|in 1|in 2|in 3|in 4|in 5|in 6"] [select name="variable_22" value=" |day(s).|week(s).|month(s)."]

As always, you may contact or return to medical for any concerns.

Respectfully Submitted, 
All dates must be entered as mm-dd-yyyy, if you do not use the drop down calendar. mm/dd/yyyy format will not work. If you don't want to enter dates, leave the field blank and nothing will populate.
SUBJECTIVE:
presents to return to work.
1. Last Day Worked:
2. First Date of Disability/Date Sick Leave Started:
3. Return to work date:
4. Attending provider:
5. Type of absence:
6. Medical Diagnosis:
7. Hospitalized:
8. Surgery:
9. Restrictions: If yes, list restrictions
10. Provider's written RTW note:
11. Dates coincide with sick leave:
12. Shift: Department: Supervisor:
15. Sign-in Date:

OBJECTIVE:
General: A&O x3. Calm, pleasant and cooperative. No objective/obvious signs of disability noted.
Musculoskeletal: Ambulated to clinic.

ASSESSMENT:
1.

PLAN:
1. Employee returned to work
2. RTW 1/2 completed. Copy provided to labor and employee provided 2 copies, 1 for self and 1 for supervisor.
3. RTW note from provider scanned into the EMR.
4. RTC

As always, you may contact or return to medical for any concerns.

Respectfully Submitted,

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.73, 24 form elements, 110 boilerplate words, 6 text boxes, 4 dates, 12 drop downs, 2 comments, 22 total clicks
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