General Approach to Initial Assessment and Documentation

The American College of Occupational and Environmental Medicine's (ACOEM) foundation guideline on General Approach to Initial Assessment and Documentation is intended to address the initial approach to assessment of some of the most common occupational medicine clinical problems. This approach includes a medical and occupational history, identification of body part(s) involved, effect of present illness or injury on patient's functionality, screening for disability risk factors that may affect the outcome, a detailed work history including type and duration of exposure. It is also important to maintain good recordkeeping and privacy of records when assessing patients for a work-related injury or illness. The reader is referred to ACOEM's other disorder-specific guidelines for more-specific guidance.