Certificate of Capacity - Clinical Summary

**1. Patient & Examination Details** **Patient:** [Full Name] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **DOB:** [Date of Birth] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Date of Injury:** [YYYY-MM-DD] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Date of Examination:** [YYYY-MM-DD] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Retrospective Certification:** "This certificate retrospectively covers the period from [Start Date] to [End Date]. **Reason:** [e.g., Patient was unable to attend sooner due to immobility.]" (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **2. Clinical Diagnosis** [SNOMED-CT-AU or DSM-5 full descriptive text with all relevant modifiers] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **3. Capacity Assessment** **Physical Function:** **Sit:** [Can / With Modifications / Cannot] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Stand/Walk:** [Can / With Modifications / Cannot] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Lift:** [Can / With Modifications / Cannot] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Use of Injured Limb:** [Can / With Modifications / Cannot] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Other:** [Specify other relevant physical limitations] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Comments:** [Detail specific limits on durations, weight-handling capacity (in kg), and restrictions on repetitive or sustained postures, movements, or forces.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Mental Health Function:** (Only include if a mental injury is diagnosed) **Attention/Concentration:** [Affected / Not Affected] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Memory:** [Affected / Not Affected] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Judgement/Decision Making:** [Affected / Not Affected] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Comments:** [Detail the specific effects of mental health symptoms on cognitive function, e.g., ability to handle complex tasks, interact with colleagues, manage deadlines.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Significant Dysfunction:** "The mental injury has caused significant [behavioural / cognitive / psychological] dysfunction." (Only include if a mental injury is diagnosed.) **Other Functional Considerations:** **Comments:** [Detail any functional effects of prescribed medication, e.g., drowsiness, impact on operating machinery.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Work Environment Considerations:** **Comments:** [Detail any required modifications to the physical work environment (e.g., temperature, noise, space, light) or mental health considerations (e.g., need for a low-stress environment).] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **4. Certification of Capacity** [Select one: Capacity for pre-injury employment / Capacity for suitable employment / No capacity for employment] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **5. Treatment & Return to Work Plan** **Injury Management:** [Describe treatment plan, e.g., "Continue prescribed analgesia", "Home exercise program with physiotherapist"] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Strategies to Increase Capacity:** [List specific strategies, e.g., "Pacing for tasks — 25 minutes work, 5 minutes break", "Graded walking increase of 10% per week"] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Return to Work Barriers:** [Describe physical, psychological, or workplace-related barriers, e.g., "Pain with prolonged sitting", "Fear of re-injury"] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Strategies to Address Barriers & Prevent Recurrence:** [List strategies and referrals, e.g., "Referral to physiotherapist for ergonomic review", "Referral to psychologist to address fear avoidance"] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) (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.)