NAOHP University

Here Are The Course Objectives for each Lesson

Work Related Examinations Module

PrePlacement & Fitness For Duty Exams

In the occupational medicine setting a physical examination is a completely different animal than in the family medicine or internal medicine setting.

You'll learn to conduct preplacement and fitness for duty exams in accordance with the Americans with Disabilities Act (ADA), HIPAA and other applicable employment legislation, and provide the client employer with a medical opinion on the ability to perform the essential functions of the job, with or without accommodation.

• Describe the difference between occmed exams and wellness physicals
• Perform examinations in accordance with the Americans w/ Disabilities Act - ADA
• Describe Employer responsibilities under current employment law
• Describe Occupational medicine provider obligations
• Determine if employee has a disability as defined by ADA
• Determine essential elements of the job
• Recommend additional testing in appropriate individuals
• Determine worker ability to perform essential elements
• Recommend reasonable accommodations to the employer
• Recognize other federal laws’ impact on employment determinations
• Describe which types of testing can be performed before a job offer
• Provide a Fitness for Duty report to the employer

TB Testing and Management

In the urgent care and occupational medicine environment, we are mostly concerned with TB testing for our clients, and most of those are in the healthcare setting.  Among those are hospitals, outpatient centers, dental offices, long term care facilities, home care agencies and municipal workers such as police, fire and social services.

Our discussion here focuses on performing TB testing and management in this context.

You'll learn to properly conduct TB testing, interpretation of testing, management of positive tests and appropriate referral, follow up and reporting to occupational medicine clients.

• Describe what causes TB - Tuberculosis
• Explain how TB is spread
• Explain the difference between Latent TB and Active TB disease
• Identify those at high risk of infection and progression of disease
• Identify target groups for testing in the occupational medicine setting
• Discuss different testing methods available, and when to appropriately use each
• Perform a complete medical evaluation for the presence of TB
• Explain why latent TB is treated
• Describe treatment regimens for latent TB
• Determine when to refer for treatment for TB disease
• Recommend follow up exams and testing as appropriate

bonus material:   Clinic TB Protocol    Record of Skin Test Results form    Record of IGRA Test Results form    Record of TB Treatment Form

Respiratory Fitness (Clearance) Exam

5 million workers in the United States are covered by the OSHA Respiratory Protection Standard under 29CFR1910.134.  Respirators protect workers from a wide variety of inhaled agents, including chemical, biological, and radioactive.

In most cases, if the worker is healthy enough to do the job, they are healthy enough to use a respirator for that job.

You'll recognize OSHA’s Respiratory Protection standard and the required elements of the evaluation of workers for the ability to use a respirator.

• Describe employer responsibilities under part 1910 of the Code of Federal Regulations (29 CFR 1910)
• Perform Initial and Periodic Respiratory Protection evaluations in accordance with OSHA standards
• Recommend appropriate physical examination based on responses to the OSHA Respirator questionnaire
• Recommend additional testing such as spirometry, chest xray, ECG and exercise stress testing in appropriate individuals
• Provide a Physicians’ Written Opinion to the employer
• Recommend follow up evaluation

bonus material:   Respirator Questionnaire   Physician's Written Opinion

"Normal" Spirometry

The reason I have “Normal” in quotation marks is because what I see all too often on occupational medicine and OSHA regulated exams is a spirometry test that has a result labeled “normal spirometry” when the test is in fact, invalid.

The Test is invalid when it does not meet certain quality criteria due to any combination of these factors we’re going to cover in this lesson.

You'll become aware of the factors leading to a valid spirometry test result and determine usefulness of the test within the context of occupational pulmonary fitness evaluation.

• Recognize that the spirometer used in occupational spirometry testing meets or exceeds ATS/ERS and ISO standards.
• Determine whether spirometry equipment has been calibrated and/or validated all days tests are conducted and is functioning properly
• Recognize errors in testing not detected by the equipment
• Compile essential elements of the Spirometry Procedure Manual
• Assure technician staff are properly trained
• Determine whether spirometry tests are technically valid
• Maintain a quality assurance program
• Ensure spirometry reports are complete and contain recommended documentation

bonus material:   NIOSH approved spirometry technician training schedule   Spirometry Best Practices   Valid Spirometry Poster for Technicians   Common Errors & Fixes

Asbestos Exams

Exposure to Asbestos carries significant health risks.  Pulmonary fibrosis, lung cancer, mesothelioma and other cancers can result.

Workers exposed to Asbestos are covered under the OSHA standard 29CFR1926.1011.

Employers are required to provide a medical surveillance program under the direction of a qualified licensed healthcare professional.

You'll recognize OSHA’s Asbestos standard and the required elements of the medical surveillance program.

• Describe employer responsibilities under part 1904 of the Code of Federal Regulations (29 CFR 1904) and the Occupational Health & Safety Act of 1970
• Perform Initial, Periodic and Exit Asbestos examinations in accordance with OSHA standards
• Recommend appropriate Chest Xray intervals
• Describe the B Reader Chest Xray requirements
• Provide a Physicians’ Written Opinion to the employer

bonus material: Multiple resources from CDC, NIOSH, ILO on CXR classification and B-readers  Asbestos questionnaires  Asbestos Clinical Guide   Asbestos Physicians' Written Opinion

Hazmat-Hazwoper Exams

18 million tons of hazardous substances were disposed of or released into the environment from 1998 through 2004.

Because of the seriousness of the safety and health hazards related to hazardous waste operations and emergency response, the Occupational Safety and Health Administration (OSHA) issued its Hazardous Waste Operations and Emergency Response (HAZWOPER) standard, Title 29 Code of Federal Regulations (CFR) Parts 1910.120.

We'll review the components of the OSHA Hazwoper standard 29CFR 1910.120 and conduct medical surveillance programs for employees subject to the standard.

• Describe employer responsibilities under part 1910.120 of the Code of Federal Regulations (29 CFR 1910.120)
• Identify the 3 general categories of work operations subject to the standard
• Recognize employers must institute engineering controls and work practices to reduce worker exposures to hazardous substances, and when not feasible, provide supplemental PPE (personal protective equipment)
• Conduct medical surveillance exams in accordance with a site's HASP (health and safety plan)
• Recognize additional substance specific OSHA standards may also apply to certain employee examinations
• Provide a Physicians’ Written Opinion to the employer
• Recommend follow up evaluation

bonus material:    PPE Protection Level Guide   Hazmat/Hazwoper Physicians' Written Opinion

Workers Compensation Injury Care Module

Workers Compensation Return to Work Strategies

There is plenty of research that teaches us that after an injury, returning to normal activities as quickly as possible, including work, is essential for recovery and well being.

Prolonged time loss not only costs money, but it is never truly recovered by most injured workers.  Longer term unintended consequences like deconditioning and loss of career opportunities may result as well.

As medical providers, we partner with our employer clients to return injured workers to productive activity as soon as possible.  We do this by:

• setting expectations from day one with the worker that returning to activities, including work, is vital to recovery
• communicating and coordinating all aspects of care with the employer client and/or case manager and claims adjuster
• clearly documenting progression of the case
• timely follow ups to avoid unnecessary modified or off duty
• identifying and communicating specific physical abilities for transitional work/modified duty after each visit
• assessing any impediments to return to work and aggressively evaluate as indicated with outside diagnostics or specialty consults
• aggressive physical therapy for time loss cases

Learn how to embrace early return to work strategies during the evaluation and management of work related injuries and conditions that result in successful recovery of the patient while minimizing the impact of prolonged disability.

• Distinguish best practices in worker's compensation cases vs. general health visits
• Determine work relatedness and causality of a worker’s injury or condition
• Communicate effectively with the employer to minimize time loss and disability
• Set Goals and expectations of clinical outcome and return to work functions
• Prescribe specific, function based modified or restricted duty job tasks when return to full duty is not appropriate
• Schedule follow up visits in a timely manner
• Identify impediments to return to work
• Seek specialty consultations and vocational assessments appropriately

bonus material:   Treatment Guidelines   Condition Treatment Index   Activities Prescription Form sample

OSHA Recordable Injuries

What makes an injury OSHA recordable?

What are employers required to do to track work related injuries and illnesses?

How can medical providers can help their occmed clients reduce OSHA recordable injuries?

OSHA recordable injuries are only those that meet certain criteria, including cases that are considered beyond “first aid”

Limiting care to first aid for minor cases and avoiding unnecessary time loss can reduce the number of OSHA recordable injuries for your employer clients

In this lesson you'll recognize OSHA’s general recording criteria during the evaluation and management of work related injuries and conditions and while first providing necessary medical attention to the worker, will assist the employer (client) in keeping “OSHA Recordable injuries” to a minimum.

• Describe employer responsibilities under part 1904 of the Code of Federal Regulations (29 CFR 1904) and the Occupational Health & Safety Act of 1970
• Determine work relatedness and causality of a worker’s injury or condition
• Describe the seven general recording criteria of an OSHA recordable injury or condition
• Avoid prescribing inappropriate off duty or modified duty restrictions
• In appropriate cases, limit treatment to “first aid” according to OSHA, rendering the case non-recordable
• Recognize which conditions remain “recordable” even when treatment is limited to first aid
• Avoid unnecessary time loss for these minor cases
• Reduce OSHA Recordable injuries for your employer clients
• Become an invaluable resource to your employer clients

bonus material:   OSHA First Aid List  First Aid Poster

Management of Blood Borne Pathogen Exposure & Needlestick Injuries

In this discussion we’re mostly concerned about bodily fluid exposure in health care personnel and the risk of contracting Hep B, Hep C and HIV infection.

This session does not replace OSHA required training of HCP under the blood borne pathogens standard, rather here we’ll review current recommendations for post exposure prophylaxis and management.

So once you have your own employees or an occupational medicine client presenting with an exposure, we’ll walk through the procedures you need to take to properly determine whether an exposure has occurred, evaluate the patient and source individuals for presence of infection or immunity from HepB, HepC and HIV, recommend post exposure prophylaxis and follow up procedures.

We include resources for the PEP hotline and forms and worksheets you can use in your practice.

You'll clinically manage exposures to blood borne pathogens according to US Public Health Service recommendations, provide post exposure prophylaxis and immunizations as indicated and provide documentation and reporting consistent with OSHA's Blood Borne Pathogen standard 1910.1030. 

• Define a blood borne pathogen exposure and determine necessary elements of an incident required to be considered an exposure
• Evaluate an exposure for the potential to transmit Hepatitis B (HBV), Hepatitis C (HCV) and Human Immunodeficiency virus (HIV)
• Determine the risk of contracting HBV, HCV, and HIV from an exposure.
• Identify conditions indicating a higher degree of risk of infection.
• Treat the exposure site
• Correctly report and document the incident
• Evaluate the Source Person (SP) or receive documentation about the SP from other sources
• Evaluate the Exposed Person (EP) and determine susceptibility and  immunity to HBV
• Assess the likelihood of transmission of HBV, HCV or HIV when the SP is unknown or cannot be tested
• Administer post exposure prophylaxis (PEP) when indicated for HBV and HIV
• Refer the EP for early treatment of HCV when indicated
• Counsel the EP on risk of transmission, PEP, side effects, follow up testing, precautions to prevent secondary transmission and allowable activities post exposure
• Perform follow up for testing according to type of exposure and PEP and for needed immunizations
• Provide a "Physician's Written Opinion" to the employer for work related exposures

bonus material:  Post Exposure PEP chart  PEP Quick Guide   Update Public Health Service Guidelines   CDC + Other Federal Guides  BBP Exposure management worksheet  Hep B Postexposure Immunization Record    BBP Physician's Written Opinion