Work Restrictions in a QME Report: Writing Them So an Employer Can Act on Them
Short answer: work restrictions are the part of a California medical-legal report that describes what the injured worker can and cannot physically do at work, stated as activities, quantities, and durations. They are separate from the impairment rating and, for injuries since 2005, do not change it. They matter because the employer has to act on them: under Labor Code 4658.7, an employer has 60 days from receipt of the first permanent and stationary report to offer regular, modified, or alternative work that fits the restrictions, or the worker receives a supplemental job displacement voucher. Restrictions written as "light duty" or "no heavy lifting" cannot be acted on. Restrictions written as "lift up to 20 pounds occasionally and 10 pounds frequently, no overhead work with the right arm, no ladders" can.
Perry J. Carpenter, DC, QME's report writing course covers return-to-work capacity in Session 5 (video) and work restrictions in Session 6 (video). His two recurring points are that employers rarely provide a usable job analysis, so the evaluator usually has to reconstruct the job from the history, and that restrictions need practical specificity, in real-world job terms, or the parties cannot use them.
A restriction is not an impairment
New evaluators sometimes assume that a restrictive set of work limitations will raise the permanent disability rating. For injuries on or after January 1, 2005, it does not. The rating is built from the whole person impairment under the AMA Guides, adjusted for occupation and age by fixed tables. The evaluator's work restrictions are not an input.
That was not always true. Under the schedules in force before 2005, disability was rated in part from work restrictions, and the old schedule had a vocabulary for them: preclusion from heavy lifting, from very heavy work, from prolonged standing, from repetitive motions of the neck. Those phrases still circulate, and they are still a reasonable shorthand in conversation, but for a post-2005 injury they are not the rating basis, and a report that offers them as the whole of the restriction section is behind by two decades.
What work restrictions do, for a current injury, is describe the disability in the plain sense of the word: what the person can no longer do. They drive the return-to-work decision, the voucher, and the vocational questions that come up in settlement. They are also often the section of the report the worker reads most closely, because it is the one that says whether they can go back to their job.
Reconstructing the job
A restriction only means something against the demands of a job, and the evaluator usually does not have a job description. Dr. Carpenter's advice is to build one through the history. What did the worker do on a normal shift? How much lifting, how often, from what height to what height? How much time standing, walking, sitting, kneeling, climbing? What tools or equipment? What was the heaviest thing handled in a typical week, and what was the heaviest thing handled ever? Was there overtime, a second job, a physically demanding commute?
The answers go in the occupational history and are the basis for the return-to-work opinion. When a formal job analysis has been served, the report should say so and should address it directly. When the worker's description and the employer's job description disagree, the report should note the disagreement and say which version the opinion is based on and why.
The vocabulary that employers understand
The U.S. Department of Labor's Dictionary of Occupational Titles defines physical demand levels that claims administrators, vocational counselors, and employers all use. Stating restrictions in these terms, or at least consistently with them, is the single largest improvement most reports can make.
| Level | Lifting and carrying |
|---|---|
| Sedentary | Up to 10 pounds occasionally; mostly sitting, with occasional walking and standing |
| Light | Up to 20 pounds occasionally and 10 pounds frequently; or significant walking or standing; or sitting with pushing and pulling of controls |
| Medium | Up to 50 pounds occasionally and 25 pounds frequently |
| Heavy | Up to 100 pounds occasionally and 50 pounds frequently |
| Very heavy | More than 100 pounds occasionally and more than 50 pounds frequently |
The frequency terms are also defined. Occasional means up to one third of the workday. Frequent means one third to two thirds. Constant means more than two thirds. "No repetitive lifting" is ambiguous; "lifting up to 25 pounds on an occasional basis only" is not.
A restriction to sedentary work, which is what "what is sedentary work restrictions" is asking, means the worker can lift up to about 10 pounds now and then and must be able to sit for most of the day. Whether a particular job qualifies as sedentary is a vocational question, but the physician's restriction is what starts it.
What a restriction should specify
Work restrictions are usually written body part by body part, and for each restricted activity the report should state the activity, the limit, and the frequency. The activities that come up most:
- Lifting, carrying, pushing, and pulling, with weights and frequencies, and floor-to-waist versus waist-to-shoulder where it matters.
- Sitting, standing, and walking, in minutes or hours at a time and total per shift, with any need to alternate positions.
- Bending, stooping, twisting, squatting, kneeling, and crawling.
- Climbing ladders and stairs, working at heights, and balancing.
- Reaching, especially overhead, and by side.
- Fine manipulation, grasping, keyboarding, and vibrating tools, with hand and frequency.
- Driving, operating machinery, and any restriction tied to medication.
- Environmental limits: temperature extremes, wet surfaces, noise.
- For psychiatric injuries, limits on interpersonal contact, supervision, pace, and hours.
Each restriction should trace to a finding. A no-overhead-reaching restriction follows from measured loss of shoulder abduction and the surgical history; a 20-pound lifting limit follows from the lumbar fusion and the residual findings. A restriction with no finding behind it is the same kind of conclusory opinion that fails the substantial evidence test everywhere else in the report.
The section also has to say whether the restrictions are permanent. Temporary restrictions belong in a report that finds the worker not yet permanent and stationary, and should carry an expected review date. Permanent restrictions belong in the P&S report and are what the employer acts on.
Finally, a short statement on whether the worker can return to the usual and customary occupation, with or without the restrictions, closes the section. The answer is yes, no, or yes with modifications, followed by the reasoning.
Prophylactic restrictions
A restriction can be justified to prevent re-injury as well as to accommodate a current limitation. A worker with a healed but structurally compromised spine may be capable of lifting 50 pounds today and be at real risk of a recurrence if they do it every day. The Guides rate the impairment as it is; the work restriction can look ahead. The report should say that the restriction is prophylactic and explain the risk, because the finding behind it is the structural condition and the clinical course rather than a present inability.
The form that starts the clock
For injuries on or after January 1, 2013, Labor Code 4658.7 gives the employer 60 days from receipt of "the first report received from either the primary treating physician, an agreed medical evaluator, or a qualified medical evaluator" finding the disability permanent and stationary with permanent partial disability, "in the form created by the administrative director," to make an offer of regular, modified, or alternative work lasting at least twelve months. If no qualifying offer is made, the worker receives a supplemental job displacement voucher of up to $6,000 for retraining and related expenses.
The form is the Physician's Return-to-Work & Voucher Report, DWC-AD 10133.36. Under 8 CCR 35.5(c)(2), a QME who finds the worker permanent and stationary with permanent partial disability must complete it and serve it with the report. It asks for the work capacities and activity restrictions, whether the worker can return to the usual occupation, and whether a job description was reviewed. It is the document that the claims administrator forwards to the employer, so the restrictions on it have to be the same as the restrictions in the report, and both have to be usable by someone who has never read a medical record.
Modified and alternative work are defined in Labor Code 4658.1. Modified work is the worker's regular job, changed so that the worker can perform all of its functions. Alternative work is a different job the worker can perform. In either case the work must pay at least 85 percent of the pre-injury wages, be within a reasonable commuting distance, and last at least twelve months.
What happens when the employer cannot accommodate the restrictions
This is the question injured workers search for most, and the honest answer is that the workers' compensation system does not require the employer to create a job. If no regular, modified, or alternative work meeting the statutory definition is offered within the 60 days, the consequence within workers' compensation is the voucher. The permanent disability award is paid regardless. The worker's employment status is a separate matter governed by other law: the interactive process and reasonable accommodation obligations under the Fair Employment and Housing Act, and the prohibition in Labor Code 132a on discriminating against a worker for having filed a claim. Whether an employer may end the employment when it cannot accommodate the restrictions is a question for an employment attorney, not the QME.
What the QME controls is whether the restrictions were written clearly enough for the employer to evaluate accommodation in good faith. An employer that receives "light duty, no heavy lifting" has no way to know whether the stockroom job qualifies. An employer that receives the DOT-level restriction, with the specific overhead and ladder limits, can compare it to the stockroom job's demands and answer.
The section, in order
- Occupational history: the job as actually performed, and whether a job analysis was reviewed.
- Current work status: working, off work, modified duty, since when.
- Restrictions by body part, each with activity, limit, frequency, and the finding it rests on.
- Whether the restrictions are permanent, or temporary with a review date.
- Whether the worker can return to the usual and customary occupation, with or without the restrictions.
- The Physician's Return-to-Work & Voucher Report, completed consistently with the above and served with the report.
The occupational history and the current work status come from the interview and the records, and the records are where the prior restrictions live: every treating physician's work status note, every PR-2 with a modified duty box checked, the therapist's functional capacity findings, the employer's offer letters if any were produced. A permanent restriction that is looser than the treating physician's last temporary restriction, with no explanation, will draw an objection; one that is tighter, with no explanation, will draw a different one. Lexamed's chronology pulls the work status entries out of the production with dates and page citations, so the evaluator can see the sequence of restrictions the worker has been under and write the permanent ones against it. The physician then writes the permanent restrictions against a documented sequence instead of from memory of the interview.
Frequently asked questions
What are work restrictions in workers' comp? Limits a physician places on the physical or mental activities an injured worker can perform at work, stated as activities, amounts, and frequencies: for example, lifting no more than 20 pounds occasionally, no overhead reaching with the right arm, and no ladders. In a California QME report they appear in the work status section and on the Physician's Return-to-Work & Voucher Report.
Do work restrictions affect the permanent disability rating in California? For injuries on or after January 1, 2005, no. The rating is calculated from the whole person impairment under the AMA Guides, adjusted for occupation and age by fixed tables. Work restrictions describe functional limits for return-to-work purposes and do not change the rating.
What is the difference between permanent and temporary work restrictions? Temporary restrictions apply while the worker is recovering and carry an expected review date. Permanent restrictions are stated in the permanent and stationary report, are not expected to change, and are what the employer must consider when deciding whether to offer regular, modified, or alternative work.
What are sedentary work restrictions? A restriction to sedentary work, as defined in the Dictionary of Occupational Titles, means lifting no more than about 10 pounds occasionally and spending most of the workday seated, with occasional standing and walking.
What is light duty? Light work under the Dictionary of Occupational Titles involves lifting up to 20 pounds occasionally and 10 pounds frequently, or significant standing or walking, or seated work with pushing and pulling of controls. As a work restriction, "light duty" on its own is too vague; the report should state the specific limits.
What happens if an employer cannot accommodate work restrictions in California? For injuries on or after January 1, 2013, if the employer does not offer regular, modified, or alternative work lasting at least twelve months within 60 days of receiving the first permanent and stationary report, the worker receives a supplemental job displacement voucher of up to $6,000 under Labor Code 4658.7. The permanent disability award is paid either way. Whether the employment continues is governed by separate employment law.
What form does a QME complete for work restrictions? The Physician's Return-to-Work & Voucher Report, DWC-AD 10133.36, which under 8 CCR 35.5(c)(2) a QME must complete and serve with any report finding the worker permanent and stationary with permanent partial disability.