RMP Return To Work 3

[remark]
This SOAP note generates a Return to Work evaluation. 
[/remark]
[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"]

[/textarea]

[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.

[/textarea]

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]


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]







RETURN TO WORK FORM

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



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
------------------------------------








Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.21, 57 form elements, 145 boilerplate words, 20 text boxes, 11 text areas, 8 drop downs, 12 variables, 5 comments, 1 remarks, 39 total clicks
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