Functional Capacity Evaluation

[description of the purpose of the functional capacity evaluation, including referring party and reason for referral] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph in full sentences.) History of presenting condition [Summary of relevant background information including: injury date and mechanism, nature of work at the time of injury, primary diagnosis, sequence of events following the injury including investigations, treatment, procedures, return to work dates and duties, and how return to work progressed.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph in full sentences.) Past medical history [Relevant previous history including prior injuries, surgeries, ongoing conditions or factors that may impact current function.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list.) Current situation [Details of the individual's current symptoms, severity and type of pain or discomfort, reported functional limitations, current medication use and any reported side effects.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph in full sentences.) Functional tolerances [Insert table with three columns. Left column includes: sitting, walking, standing, driving, stair climbing, bending, squatting/kneeling/crouching, lifting, reaching, upper limb use. Middle column should record the individual's *reported function*, including duration of tolerance and any contextual examples provided. Right column to be completed later with *observed function*.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Format as a table.) Cognitive and social tolerances [Insert table with three columns. Left column includes: concentration, memory, thinking, communication, socialisation. Middle column should capture *reported function*, tolerance or limitations, including examples or context if provided. Right column to be completed later with *observed function*.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Format as a table.) Activities of daily living [Dot-point list covering function in areas such as self-care, domestic chores, sleep, caregiving responsibilities, physical activity or recreational movement.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as dot points.) Hobbies or avocational activities [List any hobbies or non-work activities reported by the individual, including physical demands, time commitments, and functional implications.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a short paragraph or list.) Current rehabilitation and treatment [List current rehabilitation services including frequency and duration of physiotherapy, psychology, allied health or medical specialist involvement, any self-guided programs or strategies used by the individual.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list.) Psychosocial [Describe living arrangements, household and location setup, family structure and responsibilities. Identify relevant psychosocial issues under the domains of worker (e.g. identity, motivation), workplace (e.g. relationships, support), health care systems (e.g. access, communication), and insurance systems (e.g. claims, disputes). Include any expressed mental health concerns, support networks, social engagement levels, and behavioural responses such as fear-avoidance or catastrophising.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph format.) [Assessment of the individual's consistency of effort throughout the evaluation. Include observations of pain behaviours, level of cooperation, and congruence or disparity between subjective reports and objective performance findings.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph.) Work [List the current job role, tasks, employment status, work hours, physical and psychosocial demands. Include length of time in the current position, and if applicable, previous roles, work history and years of service in other industries or positions.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph format.) Physical assessment Observations [Record objective clinical observations made during the evaluation. This may include vital signs (e.g., blood pressure, heart rate), height and weight (with BMI calculated), handedness, use of walking aids, posture, gait, muscle tone or bulk, presence of scars, wounds, or asymmetry.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in list or paragraph format.) Aerobic fitness [Insert table recording the results of the 3-minute step test or equivalent aerobic test used during the evaluation. Include measures such as heart rate response, recovery time, and any symptoms provoked.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Format as a table.) Balance [Insert table summarising results of balance tests. Include tests such as single-leg stance (eyes open and closed), heel-toe walking, and any specific contextual balance tests such as outdoor navigation on uneven surfaces. Include results and any noted difficulties.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Format as a table.) Musculoskeletal screen [Create a table documenting results of range of motion (ROM) and muscle strength testing for the following body regions: neck, trunk, shoulders, elbows, wrists and hands, hips, knees, ankles and feet. Include grip strength results measured via dynamometer in the wrist and hand section. Document asymmetries or pain elicited during testing.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Format as a table.) Functional assessment [Create table documenting the observations and outcomes for the following functional tasks: reaching forward, reaching above shoulder height, stooping, squatting, kneeling, and stair climbing. Include functional ability and any adaptations, pain behaviours, or limitations observed.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Format as a table.) Manual lifting tolerances [Create table including the following lifting tasks: bench to floor, bench to bench, bench to shoulder, bench to above shoulder, bilateral carry, left carry, right carry. Record the safe maximal weight lifted for each and any relevant performance observations.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Format as a table.) Specific functional tasks [List and describe tasks that are specific to the individual's job or pre-injury role. Include task demands, observed performance and any reported or observed limitations. Examples may include typing, writing, handling equipment, use of tools, ladder use etc.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list or paragraph.) Findings and recommendations To be completed after by the clinician. (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)