Driver Fitness Determination Exam (DOT)

The Federal Motor Carrier Safety Administration (FMCSA) requires every driver undergo a physical examination to determine their fitness for duty. A Driver Fitness Determination encounter, often shortened to Driver Fitness or referred to as a DOT encounter, is modeled off of the standards (49 CFR 391.41-391.49) for the Medical Examination Report for Commercial Driver Fitness Determination–FMCSA Form MCSA-5875 and Certificate MCSA-5876–which are used to show and certify a driver’s fitness for duty. Enterprise Health has designed its Driver Fitness encounter with these standards in mind. With this encounter clinicians are able to easily capture all necessary data, electronically and discretely, making documenting the various components of Form MCSA-5875 and Certificate MCSA-5876 easier than it ever has been.
The Driver Fitness encounter allows electronic data capturing by way of predefined and structured text fields, which are coded for easier data retrieval and accessibility. Data from the encounter can be programmed to overlay forms that are then able to be printed, faxed, submitted, and/or provided as copies. Given its design, the encounter not only streamlines the workflow of determining driver fitness, but it also saves clinicians valuable time through the ability to overlay data on necessary documents, thus reducing the burden of repeatedly documenting the same information for various reporting needs.

Driver Fitness Determination - Federal

The Department of Transportation (DOT) physical exam is the default for commercial drivers who are examined in accordance with Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49). Regardless of whether driver fitness determinations need considered according to interstate or intrastate operations, the Enterprise Health Driver Fitness Determination encounter can be used to assess and certify drivers, accordingly.
To add and open a Driver Fitness Determination encounter, first navigate to the patient chart and click the Add Driver Fitness Determination link, found in the Quick Links portlet of the patient’s Summary.

Like any encounter, once it has been created and opened, the encounter navigation toolbar will load with the respective navigation and staging buttons. The navigation buttons are determined by the various categories available within the encounter, used to group the information and collected data. In this case, the Driver Fitness encounter has three categories: 1) Driver Information, 2) Examination Report, and 3) Plan. Each of these can be clicked and used as quick links to the respective section found within each category.

Driver Information (Section I)

The first part of the encounter is the Driver Information section. Within this section, there are fields available for defining the intent of the encounter, as well as for collecting the driver’s general demographic and health information. These fields are found within the Certification Type, Personal Information, and Driver Health History sections.

Certification Type

To begin, users will need to determine what type of certification is being considered for the visit–New Certification, Recertification, or Follow-up. Depending the type selected, the encounter will load the relevant data available within the patient’s chart. To select the certification type, click the section header or the edit (pencil) icon to open the section and choose, accordingly.

• New Certification - Pre-populates data within the Personal Information section.
• Recertification - Pre-populates data within the Personal Information and Health History sections, based on the previous Driver Fitness encounter.
• Follow-up - Pre-populates data within the Personal Information, Health History, Driver Health History Review, Testing (including Vision and Hearing), and Physical Exam sections, based on the previous Driver Fitness encounter.

Once the certification type is selected, click the Next button.

Personal Information

The Personal Information section is designed to pull in and pre-populate the demographic and driver information relevant to the Driver Fitness encounter. It is important to note that this information cannot be edited from within the encounter and will need updated using the Demographics tab, sometimes found under the Admin chart tab. Other information, such as the Driver License Number and Issuing State for example, will be provided via the Driver Fitness Determination questionnaire. Driver ID Verified By - This field is required by the medical staff/examiner, to verify the type of identification used to verify the driver’s identity (e.g., Driver’s License, Passport, CDL, etc.) After providing the type of identification used, click the Next button. The Driver Health History section will open.

Driver Health History

The Driver Health History section is used to document surgical history, current medications, general demographics, past medical history, and any current conditions/problems. The majority of this information pulls forward from previous exams, as well as any information gathered via questionnaires accessed through the portal (if opted into). In other words, with the portal, users have the ability to fill out a DOT questionnaire electronically, and all the collected information and previous exam data will be pulled into the Driver Fitness encounter, accordingly. Any previously documented surgeries will be listed under Surgeries, and can be edited or added to, as needed. Ensure all information is correct and up-to-date.

Following Surgeries is Medications, where all currently prescribed medications will be listed. These can be edited or added to, as needed. Ensure all information is correct and up-to-date.

Depending on whether or not a portal has been configured for the client, users will be able to either review past medical history and general questions answered by the driver, or enter the responses manually, using the point-and-click functionality within the encounter. Once the information is verified and up-to-date, be sure to review the listed conditions recorded for the driver, shown at the bottom of the questionnaire.

Once all of the information has been entered and reviewed, click the Next button to continue.

Examination Report (Section II)

The Examination Report section is intended to allow the medical staff/examiner to follow up with and address any of the information provided by the driver, as well as perform an examination of the driver’s hearing, vision, and overall body systems. The sections contained are the Driver Health History Review, Testing, and the Physical Examination.

Driver Health History Review

The Driver Health History Review allows the medical staff/examiner to review and discuss any pertinent questions answered by the driver when providing their health history.

Once all necessary information has been reviewed and documented, click the Next button to proceed to the following section.

Testing

Under the Testing section, users can record the driver’s pulse, blood pressure, height/weight, as well as urinalysis results and vision/hearing findings. When recording the findings for visual acuity under the Vision section, users will not only have the general questions to answer, they will have the ability to select the preferred method for obtaining and recording visual acuities (i.e., Snellen test or Comprehensive test).

Only one method needs to be used when obtaining and recording visual acuities: Snellen

or Comprehensive

After performing vision testing, screening for hearing loss can be done in the following Hearing section. Here, users can test and record the findings one of two ways: 1) Whispered voice at not less than 5 feet away with or without hearing aids, or 2) Audiometric testing. Whispered voice

Audiometric test

Once all testing has been performed and recorded, click the Next button to continue to the following section.

Physical Examination

The final portion of the Examination Report is the Physical Examination section. Here, the provider can check all body systems for any abnormalities. This section is designed to pull forward the previous exam information, if there is any available within the chart.

Once completed, click the Next button.

Plan (Section III)

Under the Plan are various sections intended to provide all of the necessary information relevant to the Medical Examiner Determination. The included sections will be used to add/create orders for testing or procedures, ensure all required information is documented, print any necessary documents or forms, and review/complete orders.

Visit Orders

The Visit Orders section allows the provider to add and/or create orders for additional testing or procedures that may be needed. Simply fill in the autocompletes as appropriate, and click the Add button to create the order. This will also create an additional header at the end of the encounter, for each order entered. For additional details on entering orders from an encounter, see the Working in a Dynamic Encounter online help documentation.

After adding any necessary orders, click the Next button to proceed to the following section.

Required Items

The FMCSA requires specific information to be provided and completed on the standard paper Form MCSA-5875 and Certificate MCSA-5876. Because of this, Enterprise Health has designed the Required Items section to display any item required for the FMCSA documentation that has been missed or unaddressed. Clicking any of the item hyperlinks will jump to the section that is missing the required data.

Medical Examiner Determination

Under the Medical Examiner Determination section the medical staff/examiner will review the information and complete the report, as appropriate. Users have access to a Guideline Recommendations hyperlink, if necessary. When clicked, Instructions for Completing the Medical Examination Report Form MCSA-5875 will expand on-screen, with a link to the FMCSA’s website.

Recommendations

Any recommendations or information for a Work Status Report can be addressed using the Recommendations section. To generate a Work Status Report, simply click the Recommendations section header to expand the section, and below the grid displaying recommendation(s) (i.e., medical opinion) there is a checkbox to Generate work status report. Placing a checkmark in this field will trigger the creation of a Work Status Report as an Additional View, upon archive and close of the encounter. The Work Status Introduction free text field is designed to allow for an introduction, or a place where the report can be personalized or expanded content can be provided, if necessary.

For more information on adding recommendations or generating a Work Status Report, see the Work Status online help documentation.

Printing DOT Forms

Once the examination is completed and all required documentation is accounted for, the Print DOT Forms section can be used to access and print any of the necessary forms. Simply use any of the links to print the appropriate forms.

These forms and certificate are overlaid with all of the relevant information required by the FMCSA that was recorded in the Enterprise Health system.

Complete Orders

Any pending orders will display under Compete Orders section. It will display if the order is pending or has been completed.

By clicking the Complete Orders header, users are able to review and complete any orders pending in the patient’s chart.

As noted, any orders created from the Visit Orders section will be displayed under a separate heading, below the Complete Orders section.

After all documentation within the encounter is completed, the user will scroll to the bottom of the page and click the Save Incomplete (or the Save Incomplete & View) button. This will save all of the information and release the encounter.

If there were order requests made from the encounter, the encounter view will provide the ability to view, complete, edit, or batch the order request(s), as needed.

Archive and Close the Encounter

Once the provider has finished all of the necessary documentation, the user will click the Archive & Close button, at the end of the encounter. Doing this will mark the encounter closed, and the encounter will be stored within the Enterprise Health system as a document with a doc ID.

Driver Fitness Determination - State

For drivers that do not qualify for interstate operations, the driver fitness determination is made according to state standards. As referenced in the Medical Examiner Determination section, users have the option to change the radio button from Federal to State, which will update the fields, accordingly.

Driver Fitness Determination - Certificate

The Driver Fitness Determination Certificate (MCSA-5876) must be validated with the Medical Examiner’s accreditation and credentials.

• Medical Examiner’s Accreditation - This section certifies that the driver is fit for driving duties and lists any qualifications, exemptions, and/or stipulations.
• Medical Examiner’s Credentials - A wet signature is required, along with the examining provider’s credentialing information, such as the Medical Examiner phone number, State Medical Licence number, National Registry Number, and Certificate or Registration number with issuing state. Instructions and regulations for Completing the Medical Examination Report Form (MCSA-5875) and Certificate (MCSA-5876) can found at https://www.fmcsa.dot.gov/regulations/medical