RMP Return To Work 3

This SOAP note generates a Return to Work evaluation. 
[comment memo="RETURN TO WORK 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"] [text name="upper_he_she" default="He/She"] [text name="his_her" default="his/her"] [text name="upper_his_her" default="His/Her"]    
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"]

[comment memo="Return to Work/Medical Leave Information"]

Last Day of Work [text name="last_day_worked"]

Reason for medical leave
[text name="reason_for_FFD"]

[comment memo="medical conditions causing problem" memo_size="small" memo_color="blue"]
Medical Cause(s): [textarea name="medical_conditions"][/textarea]

[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="upper_he_she"] is currently on medical leave, and comes in for an evaluation for return to work. [var name="upper_he_she"] last worked [var name="last_day_worked"].

I explained to the employee that this evaluation is a routine part of the return to work process and that their medical records are confidential. 

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

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


[comment memo="additional comments about leave, other additional introduction info" memo_size="small" memo_color="blue"][textarea name="medical_leave_history"][/textarea]

Manager's Return to Work Concerns 
[textarea name="manager_narrative"]
Their manager has no concerns about their performance or return to work.


Return to Work Concerns

I asked the employee if they had any concerns about returning to work, including specifically concerns about workplace harassment or hostility, and [var name="he_she"] said [textarea name="prevent_further_problems"]they felt safe at work and had no concerns. [/textarea]

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

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

[textarea name="pmh"][/textarea]

Family history is not obtained. 

Living Situation
   [select name="living_situation" value="|lives alone|lives with spouse|lives with family"][text name="living_situation_text"]
   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"]
   [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]

[textarea name="review_of_systems"]As noted in the history. 


[textarea name="objective"]
[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('')"]
[link url="//www.ncbi.nlm.nih.gov/pubmed/17068312" memo="#1"] Tariq (2006) Am J Geriatr Psychiatry 14:900-10

[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.



Demographic Information

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

Return to Work/Medical Leave Information

Last Day of Work

Reason for medical leave

medical conditions causing problem
Medical Cause(s):

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. upper_he_she is currently on medical leave, and comes in for an evaluation for return to work. upper_he_she last worked last_day_worked.

I explained to the employee that this evaluation is a routine part of the return to work process and that their medical records are confidential.

Employee's Narrative

additional comments about leave, other additional introduction info

Manager's Return to Work Concerns

Return to Work Concerns

I asked the employee if they had any concerns about returning to work, including specifically concerns about workplace harassment or hostility, and he_she said




Family history is not obtained.

Living Situation




Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.61, 109 form elements, 146 boilerplate words, 20 text boxes, 11 text areas, 3 checkboxes, 46 drop downs, 1 links, 12 variables, 6 comments, 1 remarks, 4 calculations, 5 conditionals, 80 total clicks
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