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Examination guidelines

Examination guidelines. 49 CFR 391.43. COPY OF LONG FORM: http ://www.fmcsa.dot.gov/sites/fmcsa.dot.gov/files/docs/Medical_Examination_Report_for_Commercial_Driver_Fitness_Determination_649-F%286045%29.pdf. Helpful Hints for Office Staff: WHEN SCHEDULING:

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Examination guidelines

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  1. Examination guidelines 49 CFR 391.43

  2. COPY OF LONG FORM:http://www.fmcsa.dot.gov/sites/fmcsa.dot.gov/files/docs/Medical_Examination_Report_for_Commercial_Driver_Fitness_Determination_649-F%286045%29.pdf

  3. Helpful Hints for Office Staff: WHEN SCHEDULING: Ask them when their card expires and schedule for 2-4 weeks before it will expire if possible. Ask them if they carry a 1 or 2 year card (should lead to questions about what limits the card). Ask them to bring a list of medications/doses/who prescribes. Ask them to bring their PCP’s/surgeons/specialist name/phone/address. Ask them if they have had any change in their health status since last DOT exam. If so, have them sign a ROI for those doctor’s visits. Tell them to bring their corrective lenses and/or hearing aids (if applicable), their driver’s license, and a copy of their current medical card. If they have hearing aids, it is prudent to have them see their audiologist for a full hearing exam prior DOT exam and bring record.

  4. Housekeeping details: My Recommendation: OPTIONAL: Routinely ask DOT drivers if they are willing to sign a records release when they come for a DOT examination. Two components: Release of records to FMCSA Release of records to employer Optional add on: Release of records to PCP TE: Regulatory requirements take precedence over HIPAA, but there are potential subtle interpretations that can cause problems. Therefore, it is easier during registration to ask for a full release to be signed releasing records.

  5. Medical Records: Hopefully, they come with their most recent medical records in hand to the appointment OR HAVE THEM SENT PRIOR. If not, you may have to request them after the visit which could affect their card. If they do have their records, see next slide regarding a medical record folder.

  6. DOT Driver Medical Folder: • Offer drivers a colored folder, maybe with your logo, address, and phone number printed on it for them to keep all of their medical information in, updated as needed, and bring to their DOT physicals • This folder should include: • Medications • Primary care physician • Any specialists information • Any other relevant information • Driver should bring the folder with them on the road and if desired, keep a copy of their long form in it as well. • If they should have health problems while on the road, the walk-in care or emergency department would have their past medical history available in the folder as wall as your information to call as needed regarding questions about the ability to continue driving.

  7. Report form health history (page 1)

  8. Supplemental Review of Systems: 1.) Supplemental full review of systems questionnaire on paper to have the driver fill out. 2.) Medical assistant do an electronic full review of systems in the computer with the driver. 3.) Relevant review of systems based on their answers on pg. 1.

  9. Health History: Regulation: You must review and discuss with the driver any “yes” answers. Document in the medical examiner’s comment section below health history, page 1. Recommendation: Perform a review of systems as pertinent.

  10. Medical Report Form (Page 2)

  11. Trained Assistive Personnel: NOTE: Page 2 testing can be performed by trained assistive personnel. However, the medical provider signs the examination form on page 3 which means they are responsible for and attesting to the validity of the documented test results. My recommendation: Have all “trained assistive personnel” go through a DOT medical exam Page 2 clinical competency with a medical provider which is documented and signed by the individual and the medical provider. In the future, FMCSA may require a certification for them.

  12. Urinalysis: Required • Urinalysis should be completed for each driver and documented on page 2 in the bottom right hand corner. • Specific gravity • Protein • Blood • Glucose • Additional laboratory section (bottom of page 2): findings: • If glycosuria, may want to obtain finger stick in clinic and/or order blood glucose or A1C. Document those results in this section on page 2. • If concerns about renal function based on urinalysis, history, and/or exam findings, order labs and document here OR REFER TO PCP AND DOCUMENT. • Remember, does it affect ability to drive CMV safely?

  13. Height and Weight: Required FOUND AT THE TOP OF PAGE 3: Regulation: You must measure and record driver height (inches) and weight (pounds). Note: Trained assistive personnel can measure and record. Take shoes off for both.

  14. Physical Examination (Page 3)

  15. Physical Examination: General Information Mark “Yes” for abnormalities or “No” for normal. Note: 1.) You must mark “Yes” for abnormalities even if they are not disqualifying. 2.) When documenting comments, number them to correspond with the body system number marked “Yes”.

  16. For all “Yes” marks, document the following: 1.) Whether or not the abnormality affects driving ability. 2.) If additional evaluation is needed to determine fitness for duty. 3.) Note if attaching relevant supplementary medical evaluation. 4.) Document your discussion with the driver, which may include advice to seek additional evaluation of a condition that is not disqualifying but could, if neglected, worsen and affect driving ability and should, in general, be medically evaluated further. 5.) Indicate whether or not the body has compensated for the organic disease adequately to meet requirements.

  17. NEXT SLIDES HIGHLIGHT PAGE 3 EXAMINATION REQUIREMENTS

  18. General Appearance: Posture, limps, or tremors Affect and overall appearance Demeanor Response to questioning Markedly overweight Signs of alcohol and/or drug abuse

  19. Eyes: Pupillary equality Reaction to light and accommodation Ocular motility Ocular muscle imbalance Extraocular movement Nystagmus Exophthalmos NOTE: Referral to vision specialist may be required.

  20. Ears: Scarring of tympanic membranes Occlusion of the external canal Perforated eardrums Check for signs of hearing loss or disturbance in balance 1.) Referral to hearing specialist may be required. 2.) Meniere’s disease can affect safety, and guidelines recommend not to certify the driver.

  21. Mouth and Throat

  22. Consider any mouth/throat disease and mouth or throat cancers and if stabilized and is treatment effective and well tolerated.

  23. Heart: Murmurs Extra sounds Enlargement Pacemaker Implantable Cardioverter Defibrillator (DISQUALIFYING) Check lower extremities for pitting edema and other signs of cardiac disease Abnormalities likely to cause syncope, dyspnea, collapse, or congestive cardiac failure Is surgery or pharmacologic treatment needed? Is the condition stabilized and treatment effective and well tolerated?

  24. Lungs and Chest: (no breast exam required) Abnormal wall expansion Respiratory rate Breath sounds Wheezes or alveolar rales Impaired respiratory function Cyanosis Clubbing of the fingers or other systemic signs of pulmonary disease Should you obtain oxygen saturation, pulmonary function tests, or blood gases?

  25. Abdomen and Viscera: Enlarged liver Enlarged spleen Masses Bruits Hernia Significant abdominal wall muscle weakness Tenderness Auscultate bowel sounds

  26. Vascular System: Abnormal pulse Abnormal amplitude Carotid or arterial bruits Varicose veins Pedal pulses

  27. Genitourinary System: Hernias Urinalysis as previously discussed

  28. Extremities-Limb Impaired: Fixed deficits of the extremities Loss, impairment, or deformities Perceptible limp Examine arms, hands, fingers, legs, feet, and toes Atrophy, weakness, or hypotonia or other signs of progressive musculoskeletal conditions Grasp and prehension needed to maintain steering wheel grip Mobility and strength in lower limbs to operate pedals properly Clubbing or edema of extremities that indicates heart, lung, or vascular conditions Driver with a fixed deficit may be subject to Skill Performance Evaluation (SPE) certificate if otherwise qualified (EXPLAINED LATER)

  29. Spine/Other Musculoskeletal: Previous surgery Deformities Limitations of motion Tenderness Diagnosis or signs of a condition known to be associated with acute episodes of transient muscle weakness, poor muscular coordination, abnormal sensations, decreased muscular tone, and/or pain. If so, ask the following questions: Nature and severity Degree of limitation Likelihood of progressive limitation Likelihood of gradual or sudden incapacitation

  30. Neurological: Impaired equilibrium Impaired coordination Impaired speech pattern Ataxia Deep tendon reflex symmetry Patellar reflex symmetry Babinski’s reflex Sensory or positional abnormalities

  31. Record Keeping: DO NOT LEAVE ANY PART OF THE LONG FORM BLANK. Your office keeps the medical form and gives the driver a copy if requested. Certification/Issuing Card: Max is 2 years. (3 months, 6 months, 12 months, other): give reason if limiting Be sure information on MEDICAL card is complete and accurate. Keep a copy of the medical card in the patient’s chart. Driver gets the original. Review the expiration date with the driver. NOTE: A driver is certified from the date of examination. Ex: Awaiting medical records- When medical records are received and determine to certify the driver, certify from date of the examination.

  32. Record Keeping: Attention to detail: If corrective lenses and/or hearing aids are required- 1.) Mark it on Pg. 3 and on the medical card. 2.) Be sure to review with the driver that they must wear their corrective lenses and/or hearing aids AT ALL TIMES when driving. Additionally 3.) If they are required to wear corrective lenses, instruct them to bring a second pair for backup. 4.) If they are required to wear hearing aids, instruct them to keep spare batteries with them when driving. 5.) Document that you told the driver this OR have a standard letter that easily prints with instructions concerning above and copy is put in the chart.

  33. Record Keeping: Retain driver medical records for a minimum of three years.

  34. Medical Card-SPE If “otherwise qualified” besides failure to meet one or more of the limb requirements, you can issue a medical card but mark “Skill Performance Evaluation” (SPE) Certificate on page 3 and on the medical card. The driver cannot drive without having the medical card AND the SPE certificate. You start the process of them getting an SPE by stating they are “otherwise qualified”. SPE’s are issued for 2 years.

  35. Medical Card: Federal Exemption If “otherwise qualified,” mark accompanied by a ______________ waiver/exemption. Enter type of exemption on the line and circle exemption. A copy of their Medical Examination Report form is required with both the initial and renewal federal exemption applications. Exemptions for diabetes and vision ONLY. The driver cannot drive without having the medical card AND the exemption certificate.

  36. Medical Card:By Operation of 49 CFR 391.64 Applies to a small number of drivers who participated in FMCSA studies conducted prior to the exemption programs. They are “grandfathered in”. They must present documentation of above at time of examination. Verify they continue to meet 49 CFR 391.64 requirements. Verify they are “otherwise qualified”.

  37. Medical Card: Driving Within an Exempt Intracity Zone Applies to a small number of drivers who participated in this program/exemption issued in 1988. They are “grandfathered in.” They must present documentation of above at time of examination. Verify they continue to meet 49 CFR 391.62 requirements. Verify they are “otherwise qualified.”

  38. Medical Card: Disqualify Mark “Does not meet standards” Note the reasons. Review the reasons with the driver and document that discussion. Do not issue a medical card.

  39. Medical Card: Temporarily Disqualify Can be achieved with a simple “disqualify” with instructions to return once medical concern is stable and cleared by treating provider. Can also mark “does not meet standards” and use the line Temporarily Disqualified due to (condition or medication): ___________________ Return to medical examiner’s office for follow-up on: ________________________ Temporarily Disqualified due to: Post-CABG 6 weeks (DOS: 1/15/2008) Return for follow-up on: or after 4/16/2008 (3 month waiting period) Remind them to sign records release for specialist or PCP to send records regarding status and clearance to return to work along with any tests performed. In the example above, you would not qualify them without all records, specifically diagnostics, and clearance from the cardiologist. We will discuss more later.

  40. They might not leave with a smile

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