**First Certificate of Capacity**
**Date of Assessment:** 01/11/2024
**Job Title:** Construction worker
**Roster:** Monday to Friday, 8 am to 4 pm
**During R&R:** The worker reported resting at home and avoiding any strenuous activities.
**DOI (Date of Injury):** 20/10/2024
**MOI (Mechanism of Injury):** The worker sustained a lower back injury while lifting a heavy object on the construction site.
**PMHx (Past Medical History):**
* Nil known
**Medications:**
* Ibuprofen 400mg as needed for pain
**Allergies:**
* No known allergies
**Previous Injuries:**
* Nil known
**Current Symptoms/Treatment:** The worker is experiencing lower back pain, which is exacerbated by movement. He has been using over-the-counter pain relief and applying heat packs. He has been advised to rest and avoid heavy lifting.
**Medical Assessment:**
**Examination:** On examination, there was tenderness to palpation in the lumbar region. Range of motion was limited due to pain. No neurological deficits were noted.
**Diagnosis:** Acute lower back strain.
**Work Capacity:**
**Plan with Work Restrictions:** Some capacity for work.
* Avoid heavy lifting (over 5kg).
* Avoid prolonged sitting or standing.
* Frequent breaks to change position.
**Injury Management Plan:**
* Continue with over-the-counter pain relief as needed.
* Apply heat packs to the affected area.
* Follow-up appointment in two weeks.
* Referral to a physiotherapist for further assessment and management.
**First Certificate of Capacity**
**Date of Assessment:** [insert the date the assessment was performed in DD/MM/YYYY format] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**Job Title:** [document the worker's job title as described] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**Roster:**
[document the worker's roster details] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**During R&R:**
[note any physical activity or lack thereof during the worker's rest and recreation period] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
**DOI (Date of Injury):**
[transcribe the date of the injury] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**MOI (Mechanism of Injury):**
[describe how the injury occurred as reported by the worker] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
**PMHx (Past Medical History):**
[list any relevant past medical history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as bullet points.)
**Medications:**
[document current list of medications that the patient is taking, including name and dosage if available] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as bullet points.)
**Allergies:**
[note any reported allergies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as bullet points.)
**Previous Injuries:**
[document any previous injuries, especially those related to the current affected area] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as bullet points.)
**Current Symptoms/Treatment:**
[describe the worker’s current symptoms and any treatment received for the injury] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.)
**Medical Assessment:**
**Examination:**
[transcribe clinical findings including swelling, tenderness, range of motion, strength, or other relevant observations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph format.)
**Diagnosis:**
[document the official diagnosis provided by the medical practitioner] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single statement.)
**Work Capacity:**
**Plan with Work Restrictions:**
[summarise the worker's certified capacity for work] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a short sentence e.g. "Some capacity for work.")
[list all specific work restrictions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as bullet points.)
**Injury Management Plan:**
[list all components of the injury management plan, including prescribed medications, medical advice, follow-up appointments, and referrals] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as bullet points.)
(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.)
