Table 2 Medical certificate for work incapacity

0

This certificate concerns:

0.1

Assessment of work capacity at sick leave

0.2

Rehabilitation money

0.3

Disability pension

1.0

Information about the patient and employment

Name:

Year of birth:

Certificate written: date

Employer’s name and address:

2

Information of diagnosis and disease

2.1

Main diagnosis

2.1.1

Code of diagnosis

2.2

Additional diagnosis

2.2.1

Code of diagnosis

2.3

Classification: ICPC-2/ICD-10

2.4

Completely incapacitated since

2.5

Story of disease, symptoms and treatment

2.6

Current clinical status (specify date). The results of relevant investigations

2.7

Should NAV consider this to be:

2.7.1.

Occupational disease? (Yes/No)

2.7.2.

If yes: date of injury

3

Plan for medical examination and treatment

3.1

Is the patient referred for

Medical assessment (specify)?

Medical treatment (specify)?

3.1.1

Date of referral for medical assessment. 3.1.2 Expected waiting time (weeks)

3.1.3

Date of referral for medical treatment. 3.1.4 Expected waiting time (weeks)

3.2

Plan for medical examination. Specify the planned examination and time duration.

3.3

Plan for medical treatment.Specify the planned treatments and time/duration

3.4

Re-evaluation of previous plan of examination and treatment

3.5

When should the NAV office request new medical information regarding work clarification and treatment programme?

3.6

If further treatment is not relevant, give justification

4

Proposed measures beyond medical treatment

Are the following measures applicable, on a medical basis. Yes/No

If yes, which ones? a) reference to specialist, b) transport subsidy, c) graded sick leave, d) technical aids, f) unemployment benefit, g) others – which ones? Give supplementary information.

Are there any specific considerations to be made as to these measures?

If no, give justifications

5

Medically reasoned assessment of work ability

5.1

Describe how the patient's functionality is generally reduced because of disease.

5.2

Is the patient engaged in paid work or domestic work, a student, other?

Specify:

Briefly describe the type of work and the requirements:

5.3

Assessment of working capacity

Will the patient be able to

a) Resume the earlier work (No/Yes)? If yes: now/after treatment

b) Take other work

5.4

a) What is it that the patient cannot do in the present work?

b) What other possible considerations need to be taken regarding the choice of another profession/work?

6

Prognosis

a) Is the treatment assumed to produce an improved ability to work? Yes/No

b) Estimate the duration of the illness/injury.

c) Estimate the duration of the functional disability.

d) Estimate the duration of the reduced working capacity.

7

Causation

Estimate the importance of the functional disability for the reduced working capacity.

8

Optional information

9

Co-operation/Contact

Select those that should be contacted by the NAV office: The doctor/employer/NAV/others

10

Reservations

10.1

Is there anything in the certificate that the patient, for medical reasons, should not know? If yes, specify what the patient should not know.

11

The physician’s signature, etc.

11.1

Date, the physician’s name and address

11.2

The physician’s signature

11.3

Telephone number