Certificate of Capacity - Clinical Summary

**1. Patient & Examination Details** **Patient:** John Smith **DOB:** 1980-03-15 **Date of Injury:** 2024-10-28 **Date of Examination:** 2024-11-01 **Retrospective Certification:** "This certificate retrospectively covers the period from 2024-10-28 to 2024-11-01. **Reason:** Patient presented to the Emergency Department with acute lower back pain following a fall." **2. Clinical Diagnosis** Acute lower back pain (ICD-10: M54.5) secondary to fall, with associated muscle spasm. **3. Capacity Assessment** **Physical Function:** **Sit:** With Modifications **Stand/Walk:** With Modifications **Lift:** Cannot **Use of Injured Limb:** With Modifications **Other:** Limited mobility due to pain. **Comments:** Patient is unable to sit for more than 30 minutes at a time. Lifting is restricted to less than 5 kg. Walking is limited to short distances. **Mental Health Function:** **Attention/Concentration:** Not Affected **Memory:** Not Affected **Judgement/Decision Making:** Not Affected **Comments:** No significant impact of pain on cognitive function. **Significant Dysfunction:** "The physical injury has caused significant physical dysfunction." **Other Functional Considerations:** **Comments:** Patient prescribed opioid analgesics which may cause drowsiness. **Work Environment Considerations:** **Comments:** Patient requires a work environment that allows for frequent breaks and the ability to alternate between sitting and standing. **4. Certification of Capacity** Capacity for suitable employment **5. Treatment & Return to Work Plan** **Injury Management:** Continue prescribed analgesia (ibuprofen and codeine). Ice packs to the lower back as needed. Advised to rest and avoid heavy lifting. Follow up with GP in 1 week. **Strategies to Increase Capacity:** Gradual increase in activity as tolerated. Gentle stretching exercises. **Return to Work Barriers:** Pain with prolonged sitting and standing. **Strategies to Address Barriers & Prevent Recurrence:** Referral to physiotherapy for assessment and advice on ergonomic adjustments at work. Advised to maintain good posture and avoid heavy lifting.