RMP Soft Fit

[remark]
This SOAP note generates all the pieces of a Fitness for Duty evaluation at once. 
[/remark]
[comment memo="FFD REQUEST FORM" memo_size="large"]

[comment memo="Demographic Information"]

Last Name: [text name="last_name"]    First Name: [text name="first_name"]    
Age: [text name="age"]    Pronoun: [text name="he_she" default="he/she"]    
Employee ID: [text name="eid"]    Job Title: [text name="job_title"]
Start Date: [text name="start_date" ]    Department/Location: [text name="job_location"]    Employer: [text name="employer_name"]


Job Description Attached?: [select name="is_job_description_attached" value="|Job Description is attached."]
[comment memo="Optional additional job description information" memo_size="small" memo_color="blue"]
[textarea name="job_description"][/textarea]

[comment memo="Fitness for Duty Information"]

Reason why evaluation was requested
[textarea name="reason_for_FFD"][/textarea]

[select name="is_condition_identified" value="Medical conditions have been identified|Medical conditions have not been identified|"] which [select name="is_explained" value="explain |explain in part |do not explain | "] the problems in the workplace.
[comment memo="medical conditions causing problem" memo_size="small" memo_color="blue"]
Medical Cause(s): [textarea name="medical_conditions"][/textarea]

[comment memo="recommended follow-up for own medical conditions, not related to return to work" memo_size="small" memo_color="blue"]
[select name="other_conditions_identified" value="|Other conditions in need of follow-up care are identified."]
Things to review with your doctor: [textarea name="recommended_follow_up" default=""][/textarea]

Final Determination: [select name="is_unfit" value="medically unfit for duty|medically fit for duty"]


====================================


HISTORY
------------------------------------

Introduction

[var name="first_name"] [var name="last_name"], EID ([var name="eid"]), is a [var name="age"] year old [var name="job_title"] working in/at [var name="job_location"], since hired by [var name="employer_name"] on [var name="start_date"]. [var name="first_name"] [select name="is_working" value="is currently working.|is currently on leave."] 
[comment memo="additional comments about leave, other additional introduction info" memo_size="small" memo_color="blue"][textarea name="rmp_history_4"][/textarea]

Employee Contact Info 
Phone: [text name="phone"] Email: [text name="email"]

Employee's Understanding

When asked why [var name="he_she"] is here today for evaluation, [var name="he_she"] states "[textarea name="rmp_history_1"][/textarea]".

Disclaimer and Permissions 

I explained to the employee that their participation is voluntary, that their medical records are confidential. I further explained that the purpose of this visit is not punitive; it is to ascertain if a medical condition is interfering with their ability to safely do their job. 

[select name="rmp_history_2" value="The employee did not give permission to review available medical records.|The employee gave permission to review available medical records."] [select name="rmp_history_3" value="The employee did not give permission to contact their treating provider(s).|The employee gave permission to contact their treating provider(s)."]

Reason for Soft Fit Request (HR/Manager)

The employee's manager and HR have requested a Soft Fitness for Duty Evaluation because of [var name="reason_for_FFD"]. 

Manager's Narrative 
[textarea name="manager_narrative"]
An email from the manager notes the following:

Specific incidents of concern include the following:
- incident 1
- incident 2
- incident 3
[/textarea]

Employee Preface Comments: [textarea name="employee_preface"][/textarea]

Employee's Narrative
[textarea name="employee_narrative"]


The employee addresses the specific incidents of concern raised by the manager as follows:
- incident 1
- incident 2
- incident 3
[/textarea]

Return to Work Concerns

I asked the employee how further problems in the workplace can be prevented, and [var name="he_she"] said [textarea name="prevent_further_problems"][/textarea]


ALLERGIES
[textarea name="allergies"][/textarea]

MEDICATIONS
[textarea name="medications"]as noted[/textarea]

PAST MEDICAL HISTORY
[textarea name="pmh"][/textarea]

FAMILY HISTORY
Family history is not obtained. 

PSYCHOSOCIAL HISTORY
Living Situation
   [select name="living_situation" value="|lives alone|lives with spouse|lives with family"][text name="living_situation_text"]
Vices
   Tobacco:[select name="vices_smoke" value="|non-smoker|occasional smoker|heavy smoker"][text name="tobacco_text"]
   Alcohol:[select name="vices_alcohol" value="|non-drinker|occasionally drinks|drinks regularly"][text name="alcohol_text"]
   Drugs:[select name="vices_drugs" value="|no illicit drugs|occasional drug use|regular drug use"][text name="Drugs_text"]
Safety/Support
   [select name="safe_at_home" value="|Employee feels safe at home.|Employee does not feel safe at home."][text name="safe_at_home_text"]
   [select name="support_network" value="|Employee has no support network.|Employee has a limited support network.|Employee has a good support network.|Employee has an extensive support network."][text name="support_network_text"]
[textarea name="psychosocial_free_text"][/textarea]


REVIEW OF SYSTEMS
[textarea name="review_of_systems"]As noted in the history. 
[/textarea]

OBJECTIVE PHYSICAL EXAM AND TESTING
------------------------------------

[textarea name="objective"]
[/textarea]

[checkbox name="showSLUMS" value="SLUMS (Saint Louis University Mental Status Examination)"][conditional field="showSLUMS" condition="(showSLUMS).is('SLUMS (Saint Louis University Mental Status Examination)')"]
Saint Louis University Mental Status (SLUMS) Examination
1. [select name="DayOfWeek" value="Correct (1 point)=1|Incorrect (0 points)=0"] <-- What day of the week is it?
2. [select name="Year" value="Correct (1 point)=1|Incorrect (0 points)=0"] <-- What is the year?
3. [select name="State" value="Correct (1 point)=1|Incorrect (0 points)=0"] <-- What state are we in?
4. Please remember these five objects. I will ask you what they are later: apple, pen, tie, house, car.
5. You have $100 and you go to the store and buy a dozen apples for $3 and a tricycle for $20.
   [select name="Spend" value="Correct (1 point)=1|Incorrect (0 points)=0"] <-- How much did you spend?
   [select name="Left" value="Correct (2 points)=2|Incorrect (0 points)=0"] <-- How much do you have left?
6. [select name="Animals" value="0-4 animals (0 points)=0|5-9 animals (1 point)=1|10-14 animals (2 points)=2|15+ animals (3 points)=3"] <-- Please name as many animals as you can in one minute.
7. [select name="Objects" value="1 object (1 point)=1|2 objects (2 points)=2|3 objects (3 points)=3|4 objects (4 points)=4|5 objects (5 points)=5"] <-- What were the five objects I asked you to remember?
8. I am going to say a series of numbers and I would like you to give them to me backwards. For example, if I say 42, you would say 24.
   [select name="Backwards1" value="No points"] <-- 87
   [select name="Backwards2" value="Correct (1 point)=1|Incorrect (0 points)=0"] <-- 649
   [select name="Backwards3" value="Correct (1 point)=1|Incorrect (0 points)=0"] <-- 8537
9. (Draw circle.) This circle represents a clock face. Please put in the hour markers and the time at ten minutes to eleven o'clock.
   [select name="Hour" value="Correct (2 points)=2|Incorrect (0 points)=0"] <-- Hour marker correct?
   [select name="Time" value="Correct (2 points)=2|Incorrect (0 points)=0"] <-- Correct time?
10. (Show a triangle, a square and a rectangle.) 
   [select name="XTriangle" value="Correct (1 point)=1|Incorrect (0 points)=0"] <-- Please place an X in the triangle.
   [select name="Largest" value="Correct (1 point)=1|Incorrect (0 points)=0"] <-- Which of those objects is the largest?
11. I am going to tell you a story. Please listen carefully because afterward, I'm going to ask you some questions about it.
"Jill was a very successful stockbroker. She made a lot of money in the stock market. She then met Jack, a devastatingly handsome man. She married him and had three children. They lived in Chicago. She then stopped working and stayed at home to bring up her children. When they were teenagers, she went back to work. She and Jack lived happily ever after.  "
   [select name="FemaleName" value="Correct (2 points)=2|Incorrect (0 points)=0"] <-- What was the female's name?
   [select name="BackToWork" value="Correct (2 points)=2|Incorrect (0 points)=0"] <-- When did she go back to work?
   [select name="WorkDone" value="Correct (2 points)=2|Incorrect (0 points)=0"] <-- What work did she do?
   [select name="WhatState" value="Correct (2 points)=2|Incorrect (0 points)=0"] <-- What state did she live in?
12. [select name="Education" value="High School or above|Less than High School"] <-- Education?
SCORE:  [conditional field="Education" condition="(Education).is('High School or above')"][calc value="score=(WhatState)+(WorkDone)+(BackToWork)+(FemaleName)+(Largest)+(XTriangle)+(Time)+(Hour)+(Backwards2)+(Backwards3)+(Objects)+(Animals)+(Left)+(Spend)+(State)+(Year)+(DayOfWeek)" memo="score"]/30  [calc value="score=(WhatState)+(WorkDone)+(BackToWork)+(FemaleName)+(Largest)+(XTriangle)+(Time)+(Hour)+(Backwards2)+(Backwards3)+(Objects)+(Animals)+(Left)+(Spend)+(State)+(Year)+(DayOfWeek);score>26?'Normal':score>20?'Mild neurocognitive disorder':'Dementia'" memo="interpretation"][/conditional][conditional field="Education" condition="(Education).is('Less than High School')"][calc value="score=(WhatState)+(WorkDone)+(BackToWork)+(FemaleName)+(Largest)+(XTriangle)+(Time)+(Hour)+(Backwards2)+(Backwards3)+(Objects)+(Animals)+(Left)+(Spend)+(State)+(Year)+(DayOfWeek)" memo="score"]/30  [calc value="score=(WhatState)+(WorkDone)+(BackToWork)+(FemaleName)+(Largest)+(XTriangle)+(Time)+(Hour)+(Backwards2)+(Backwards3)+(Objects)+(Animals)+(Left)+(Spend)+(State)+(Year)+(DayOfWeek);score>24?'Normal':score>19?'Mild neurocognitive disorder':'Dementia'" memo="interpretation"][/conditional]  
[comment memo="note:  maximum score is 30.  27 and above is normal for high school educated adults.  25 and above is normal for those with less education."]
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference:  
[link url="//www.ncbi.nlm.nih.gov/pubmed/17068312" memo="#1"] Tariq (2006) Am J Geriatr Psychiatry 14:900-10
[/conditional]

[/conditional]
[checkbox name="showPsychMS" value="Psych Mental Status"][conditional field="showPsychMS" condition="(showPsychMS).is('Psych Mental Status')"]
Mental Status Examination:
General: [select name="variable_2" value="alert and oriented in all spheres|obtunded|disoriented"].
Appearance: [select name="variable_3" value="well kempt|poorly kempt|appropriately dressed|inappropriately dressed|appropriately groomed|inappropriately groomed"].
Behavior - general: [select name="variable_4" value="in no acute distress|in acute psychological distress"].
Behavior - stability: [select name="variable_5" value="calm|agitated"].
Behavior - interactivity: [select name="variable_6" value="warm with comments and behavior|interactive|withdrawn"].
Behavior - eye contact: [select name="variable_7" value="eye contact good|eye contact fair|eye contact avoidant"].
Mood/Affect - stated: [select name="variable_8" value="normal|upbeat|euthymic|depressed"].
Mood/Affect - emotional range: [select name="variable_9" value="normal|broad|restricted"].
Mood/Affect - intensity: [select name="variable_10" value="normal|expansive|blunted|flat"].
Mood/Affect - congruence: [select name="variable_11" value="mood is congruent with affect|mood and affect are not congruent"].
Thought form and content: [select name="variable_12" value="normal|future oriented|logical, linear and goal-oriented|past oriented and somber|goal directed|scattered|hopeful|remorseful|enthusiastic|resigned"]
Attention: [select name="variable_13" value="no difficulty with attention or concentration|had some attentional and concentration problems during the exam"].
Perception - insight: [select name="variable_14" value="normal insight|poor insight"]
Perception - general: [select name="variable_15" value="normal|hallucinations - auditory|hallucinations - auditory, talking to someone not present|hallucinations - visual|hallucinations - visual - looking at something not present|hallucinations - multiple"]
Cognition/Memory: [select name="variable_16" value="normal|grossly intact|below average|above average"].
Cognition/Memory - abstraction: [select name="variable_17" value="normal ability to abstract|difficulty with abstract thought|inability for abstract thought"]
Judgment: [select name="variable_18" value="normal|poor|good"].
Suicide/Assault: [select name="variable_19" value="no current or past ideation or intent|denies an active sense of wanting to harm self or others|present but without intent or plan|resolved"].
Patient is currently assessed to be at [select name="variable_20" value="low|moderate|high"] risk for self harm or harm to others as evidenced by ideation and behavior on today's exam.

[/conditional]


ASSESSMENT 
------------------------------------

[var name="is_condition_identified"][conditional field="is_condition_identified" condition="(is_condition_identified).is('Medical conditions have been identified')"] which [var name="is_explained"] the problems in the workplace[/conditional]. 

[var name="first_name"] [var name="last_name"] [var name="is_unfit"][conditional field="is_unfit" condition="(is_unfit).is('medically unfit for duty')"] due to [var name="reason_for_FFD"], due to [var name="medical_conditions"].

[comment memo="optional additional assessment text" memo_size="small" memo_color="blue"]
[textarea name="optional_assessment_text"]
[/conditional]

[comment memo="any other conditions that need follow-up (unrelated to FFD)" memo_size="small" memo_color="blue"]
[var name="other_conditions_identified"][conditional field="other_conditions_identified" condition="(other_conditions_identified).isNot('')"] They are instructed to talk to their provider(s) about: [var name="recommended_follow_up"][/conditional]


[comment    memo="FIT FOR DUTY INSTRUCTIONS TO EMPLOYEE"]
[var    name="email"]
INSTRUCTIONS TO EMPLOYEE: Return to Work
----------------------------------------

Dear [var name="first_name"] [var name="last_name"],

I have completed my Soft Fitness for Duty evaluation. You are fit for duty and medically cleared to return to work. [var name="is_condition_identified"][conditional field="is_condition_identified" condition="(is_condition_identified).is('Medical conditions have been identified')"] which [var name="is_explained"] the problems in the workplace, and this should be taken into account if you are currently subject to any disciplinary action[/conditional]. 

[conditional field="other_conditions_identified" condition="(other_conditions_identified).isNot('')"]Some additional concerns came up during your evaluation. Please remember to talk to your provider(s) about: [var name="recommended_follow_up"][/conditional]

Please be aware that going forward, any further problems must be treated as a performance issue, not a medical one. Performance problems may result in disciplinary action (including possibly termination for cause). 

Thank you, 

[comment memo="UNFIT FOR DUTY INSTRUCTIONS TO EMPLOYEE"]
INSTRUCTIONS TO EMPLOYEE: Medical Leave
---------------------------------------

Dear [var name="first_name"] [var name="last_name"],

I have completed my Soft Fitness for Duty evaluation. Your examination reveals [var name="medical_conditions"] which [var name="is_explained"] the [var name="reason_for_FFD"] reported in your workplace. I believe it is unsafe for you to continue working at this time.

The next steps you should take are to: take a medical leave of absence; get treatment and evaluation; and when you're ready, request a return to work. 


TAKE A MEDICAL LEAVE OF ABSENCE
-------------------------------

Please take a medical leave from work. We notify all appropriate parties (your manager/leadership, HR, and/or union if you belong to one) that you are unable to work at this time.

Contact Absence One (888-480-9282) and let them know you are unable to work and have been instructed to take medical leave, and find out about next steps to take with respect to applying for Short-Term Disability. 

Contact your Leave Management Specialist. If you don't yet have one, contact HR (844-242-HR4U) about the proper way to take a medical leave. 


GET EVALUATION AND TREATMENT
----------------------------

Make sure you get properly evaluated and treated to address the [var name="medical_conditions"], and any other medical impairments that prevent your safe return to work.  If you apply for Short-Term Disability, FMLA, or other types of leave, your treating provider will need to complete any paperwork that is sent to you. (I cannot complete any of that paperwork, as I am not allowed to treat you; I only evaluate your safety and capacity to work.) 

[conditional field="other_conditions_identified" condition="(other_conditions_identified).is('Other conditions in need of follow-up care are identified.')"]Some additional concerns came up during your evaluation, that were not necessarily related to your Fitness for Duty evaluation. Please remember to talk to your provider(s) about: [var name="recommended_follow_up"][/conditional]

REQUEST A RETURN TO WORK
------------------------

In order to return to work, I will require you to obtain medical clearance from your treating provider(s). You will need to do (or get) the following: 

[textarea name="medical_clearances"]
-Medical clearance from the ***specialist*** who is treating you for ***condition***

-Medical clearance from the ***specialist*** who is treating you for ***condition***

-Medical clearance from the ***specialist*** who is treating you for ***condition***

-Medical clearance from yor psychiatrist and/or mental health counselor. 

-If you undergo treatment specifically for alcohol use (e.g. Intensive Outpatient Program, Inpatient Rehabilitation), then you must provide documentation that you are either currently participating in the program or that you have successfully completed it. 
[/textarea]

Note that your physician(s) may request temporary accommodations if needed. Examples of typical accommodation requests include:
- no lifting > 20 pounds for two weeks
- two hours off for per week for scheduled appointments for treatment
- up to 30 minutes extra break time for bathroom use (to be made up)
- and so on.
If your medical clearance letters make no request for accommodations, then you are asking to return to work without restrictions. 

Once you have gathered all the necessary documentation, please send it to myself and the Employee Health Coordinator Samantha Mann (who is cc'd on this email). We will review it to see if it is safe for you to return to work, and whether or not we can provide any accommodations you request. 


Please be aware that once you have been medically cleared to return to work, any further problems must be treated as a performance issue, not a medical one. Performance problems may result in disciplinary action (including possibly termination for cause). Please do NOT return to work until both you and your treating physicians are certain that you are ready.  

If you have questions about the return to work process, please contact us here in Employee Health (412-359-8288); if you have questions about the Leave Process, please contact your Leave Management specialist or call HR (412-242-HR4U). 


Thank you,



====================================

NOTIFICATION TO EMPLOYER
------------------------------------


Greetings All,

I have completed my evaluation of [var name="first_name"] [var name="last_name"] EID ([var name="eid"]). [var name="is_condition_identified"] which [var name="is_explained"] the problems in the workplace. [conditional field="is_unfit" condition="(is_unfit).is('medically unfit for duty')"] These medical conditions require evaulation and treatment and [/conditional][var name="first_name"] is [var name="is_unfit"] to continue working as a [var name="job_title"] at this time. 

I recommended that [var name="he_she"] [conditional field="is_unfit" condition="(is_unfit).is('medically unfit for duty')"] take a medical leave of absence, or remain on a medical leave of absence if [var name="he_she"] has already started one. Instructions on how to follow the leave process were given both verbally and in writing. 

They may not return to work without medical clearance. I encouraged [var name="first_name"] to make sure they do not rush, and get all the evaluation and treatment that might be necessary, and reminded them that their treating provider can request accommodations if necessary. [/conditional][conditional field="is_unfit" condition="(is_unfit).is('medically fit for duty')"] return to work, with the following stipulations: [textarea name="continue_work_stipulations" default="none"][/conditional]

They understand that once they are medically cleared to work, further difficulties must be treated as a performance problem, not a medical one. Performance problems may result in disciplinary action (including possibly termination for cause). 

Please let me know if you have any questions.

Thank you,





FFD REQUEST FORM

Demographic Information

Last Name: First Name:
Age: Pronoun:
Employee ID: Job Title:
Start Date: Department/Location: Employer:


Job Description Attached?:
Optional additional job description information


Fitness for Duty Information

Reason why evaluation was requested


which the problems in the workplace.
medical conditions causing problem
Medical Cause(s):


recommended follow-up for own medical conditions, not related to return to work

Things to review with your doctor:


Final Determination:


====================================


HISTORY
------------------------------------

Introduction

first_name last_name, EID (eid), is a age year old job_title working in/at job_location, since hired by employer_name on start_date. first_name
additional comments about leave, other additional introduction info


Employee Contact Info
Phone: Email:

Employee's Understanding

When asked why he_she is here today for evaluation, he_she states "
".

Disclaimer and Permissions

I explained to the employee that their participation is voluntary, that their medical records are confidential. I further explained that the purpose of this visit is not punitive; it is to ascertain if a medical condition is interfering with their ability to safely do their job.



Reason for Soft Fit Request (HR/Manager)

The employee's manager and HR have requested a Soft Fitness for Duty Evaluation because of reason_for_FFD.

Manager's Narrative


Employee Preface Comments:


Employee's Narrative


Return to Work Concerns

I asked the employee how further problems in the workplace can be prevented, and he_she said



ALLERGIES


MEDICATIONS


PAST MEDICAL HISTORY


FAMILY HISTORY
Family history is not obtained.

PSYCHOSOCIAL HISTORY
Living Situation

Vices
Tobacco:
Alcohol:
Drugs:
Safety/Support





REVIEW OF SYSTEMS


OBJECTIVE PHYSICAL EXAM AND TESTING
------------------------------------







ASSESSMENT
------------------------------------

is_condition_identified.

first_name last_name is_unfit

any other conditions that need follow-up (unrelated to FFD)
other_conditions_identified


FIT FOR DUTY INSTRUCTIONS TO EMPLOYEE
email
INSTRUCTIONS TO EMPLOYEE: Return to Work
----------------------------------------

Dear first_name last_name,

I have completed my Soft Fitness for Duty evaluation. You are fit for duty and medically cleared to return to work. is_condition_identified.



Please be aware that going forward, any further problems must be treated as a performance issue, not a medical one. Performance problems may result in disciplinary action (including possibly termination for cause).

Thank you,

UNFIT FOR DUTY INSTRUCTIONS TO EMPLOYEE
INSTRUCTIONS TO EMPLOYEE: Medical Leave
---------------------------------------

Dear first_name last_name,

I have completed my Soft Fitness for Duty evaluation. Your examination reveals medical_conditions which is_explained the reason_for_FFD reported in your workplace. I believe it is unsafe for you to continue working at this time.

The next steps you should take are to: take a medical leave of absence; get treatment and evaluation; and when you're ready, request a return to work.


TAKE A MEDICAL LEAVE OF ABSENCE
-------------------------------

Please take a medical leave from work. We notify all appropriate parties (your manager/leadership, HR, and/or union if you belong to one) that you are unable to work at this time.

Contact Absence One (888-480-9282) and let them know you are unable to work and have been instructed to take medical leave, and find out about next steps to take with respect to applying for Short-Term Disability.

Contact your Leave Management Specialist. If you don't yet have one, contact HR (844-242-HR4U) about the proper way to take a medical leave.


GET EVALUATION AND TREATMENT
----------------------------

Make sure you get properly evaluated and treated to address the medical_conditions, and any other medical impairments that prevent your safe return to work. If you apply for Short-Term Disability, FMLA, or other types of leave, your treating provider will need to complete any paperwork that is sent to you. (I cannot complete any of that paperwork, as I am not allowed to treat you; I only evaluate your safety and capacity to work.)



REQUEST A RETURN TO WORK
------------------------

In order to return to work, I will require you to obtain medical clearance from your treating provider(s). You will need to do (or get) the following:



Note that your physician(s) may request temporary accommodations if needed. Examples of typical accommodation requests include:
- no lifting > 20 pounds for two weeks
- two hours off for per week for scheduled appointments for treatment
- up to 30 minutes extra break time for bathroom use (to be made up)
- and so on.
If your medical clearance letters make no request for accommodations, then you are asking to return to work without restrictions.

Once you have gathered all the necessary documentation, please send it to myself and the Employee Health Coordinator Samantha Mann (who is cc'd on this email). We will review it to see if it is safe for you to return to work, and whether or not we can provide any accommodations you request.


Please be aware that once you have been medically cleared to return to work, any further problems must be treated as a performance issue, not a medical one. Performance problems may result in disciplinary action (including possibly termination for cause). Please do NOT return to work until both you and your treating physicians are certain that you are ready.

If you have questions about the return to work process, please contact us here in Employee Health (412-359-8288); if you have questions about the Leave Process, please contact your Leave Management specialist or call HR (412-242-HR4U).


Thank you,



====================================

NOTIFICATION TO EMPLOYER
------------------------------------


Greetings All,

I have completed my evaluation of first_name last_name EID (eid). is_condition_identified which is_explained the problems in the workplace. first_name is is_unfit to continue working as a job_title at this time.

I recommended that he_she

They understand that once they are medically cleared to work, further difficulties must be treated as a performance problem, not a medical one. Performance problems may result in disciplinary action (including possibly termination for cause).

Please let me know if you have any questions.

Thank you,




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