SAMPLE HEALTHCARE PROVIDER DOCUMENTATION

Samples of insufficient healthcare provider (HP) documentation:

Below are examples of insufficient information from an HP’s office presented to a supervisor by
an employee.

Many times a note from the doctor’s office or other HP with brief information is not sufficient
for the RA process. The first example is a brief note that merely states what the employee wants
and can be obtained upon request from the HP office staff. It provides no or very little
information as to diagnosis, severity, limitations and/or restrictions, and how it affects the
employee while at work.

LSU Eye Center

The patient will need time off

Dr. Susan Ahn, O.D., 01/01/2020

In the second example below, even though information is presented on the physician’s letterhead
with the HP’s other required information, it does not mean that is sufficient. The example is
insufficient because it merely states the employee’s wishes, the slight change in vision does not
show a reason for a screen enlarger and six weeks of leave requested by the employee, and the
physician has not medically substantiated the need for changes in duties requested by the
employee.
 LSU Eye Center
202 Gravier Street
New Orleans, LA 70112
555-888-1234

January 1, 2020

To whom it may concern:

Mr. John Doe is my patient. He has had some slight changes in his vision noted at his last annually check up and was given a
new prescription for reading glasses.

He states that he has difficulty seeing the payroll system that he works with and processing reports and other paperwork in
his job causes him stress, but he can answer phone calls. He states that he also can not be on call or on the emergency
evacuation team. This patient should be on light duty and allowed to take only customer calls per his request.

Dr. Susan Ahn, O.D.

Because the information provided is insufficient and does not logically relate to the request made
by the employee to have a screen enlarger and six weeks of leave, the employee is then given the
following summary and questions for the physician.

Sample HP Documentation
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January 5, 2020

Dr. Susan Ahn, O.D.

Dr. Ahn:

Mr. John Doe has requested a screen enlarger for his computer and six weeks of leave for medical treatments. He has given us a note
from your office stating that he will need time off. In order to assess the employee’s request for this as a possible reasonable
accommodation or workplace modification and to provide the best solution if possible, more information is required. The response
should be faxed to a secure fax at 303-274-3873.

Please note that any charges related to this request are the responsibility of your patient and not the agency.

Mr. Doe’s position as a Financial Management Technician is sedentary and requires him to perform the following tasks:

 Review, and enter documents into an automated system intermittently during the day,
 Research information in automated systems and hard-copy files,
 Answer and respond to customer calls as needed,
 Correct and update information in automated systems, and
 Provide training to lower-graded employees when needed.

Please answer the following questions to assist us in the evaluation of his needs and making decisions on his request.

1. What is Mr. Doe’s diagnosis, its severity, the prognosis, and how does it affect his daily life?

2. Does his condition affect his sight that would cause him to need magnification of print on a computer screen beyond what
normally is used with or without glasses?

3. What is the expected length of time that the medical treatments are to last?

4. What is the expected frequency of the medical treatments?

5. What is the expected length of time for absences from work?

Sincerely,

Patricia A. Bachemin
Disability Program Manager

Sample HP Documentation
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SAMPLE SATISFACTORY HP DOCUMENTATION:

LSU Eye Center

January 15, 2020

To whom it may concern:

Mr. John Doe is under my care for Acme Syndrome of the eye. This is a progressive eye disease that can be arrested with
treatment, but any vision loss can not be regained. Mr. Doe currently has slight to moderate diminished sight in both eyes
that makes it difficult for him to read normal-sized print. His reading ability does improve to a satisfactory level with
enlarged print.

In an attempt to arrest his vision loss, he will be having weekly treatments on his eyes in my office for six weeks beginning
June 1, 2013 and ending on August 12, 2013. The treatments are normally no longer than an hour. The employee may
experience tearing and sensitivity to light for approximately two to three hours after each treatment. If he feels comfortable,
he may return to work after the treatments or rest for the remainder of the day. No other side effects are expected and his
vision should be stabilized once the treatments are completed.

Dr. Susan Ahn, O.D.

It is dated, on letterhead, with phone numbers, and signed by the physician. It provides the
diagnosis and its severity, how it affects the employee, describes the treatment, length of time,
and the prognosis after treatment.

The supervisor can now make a decision on RA requested. An effective solution to enlarge the
print on his computer screen will be found and the employee will be granted leave to receive his
treatments. Leave will also be flexible if the employee needs to use more on the day of the
treatments due to the short-term effects immediately after them. Leave would be whatever the
employee has and wishes to use; i.e., annual, sick, compensatory time, or leave without pay.

Sample HP Documentation
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