5.2 Steps in the assessment and reporting process
STEP 1: Consider the type of licence held or applied for
The type of licence will determine whether the commercial or private medical standards are referred to, in the case of examinations requested by a driver licensing authority, the authority will identify the type of licence on the request, in cases of assessment as part of an ongoing therapeutic relationship, the health professional will need to determine from the patient what sort of driver licence or authority they hold. Given the potential for patients to withhold information if their mobility or livelihood is threatened, it is helpful for health professionals to be aware of their patients’ occupations as a matter of course.
The health professional should refer to Table 3 to determine which standards to apply.
The medical standards for commercial vehicle drivers are more stringent than those for drivers of private vehicles. Thus, a person who is not eligible for a commercial vehicle licence may still be eligible for a private vehicle driver licence. In such cases, both sets of standards may need to be consulted.
STEP 2: Establish relevant medical and driving history
The nature and extent of this aspect of the assessment will vary depending on the particular circumstances. In the case of examinations requested by a driver licensing authority for the first time, a detailed history will need to be established including:
- whether the person has ever been found unfit to drive a motor vehicle in the past, and the reasons
- whether there is any history of epilepsy, syncope or other conditions of impaired consciousness including: sleep disorders; neurological conditions; psychiatric conditions; problems arising from alcohol and/or drugs; diabetes; cardiovascular conditions, especially ischaemic heart disease; locomotor disorders; hearing or visual problems
- whether the person has a history of motor vehicle incidents (crashes, near misses, driving offences)
- whether the person is taking medications that might affect their driving ability
- the existence of other medical conditions that, when combined, might exacerbate any road safety risks (refer to section 2.2.7 Multiple medical conditions and age-related change).
- the degree of insight the patient has into their ability to drive safely
- the nature of their current driving patterns and needs, for example, how frequently they drive, for what purposes, over what distances and whether they travel at night.
Special examinations called ‘for cause’ examinations may be requested by the driver licensing authority out of concern for driving behaviour, such as recurrent motor vehicle crashes or other reasons. Under such circumstances, it is desirable that all aspects of the driver–vehicle–road system (refer to Figure 1) be considered, for example, fatigue factors in the case of a commercial vehicle driver. A full medical history and history of any motor vehicle crashes should be taken and a complete physical examination conducted.
While attention should be given to conditions discussed in Part B of this publication, unusual conditions or the effect of multiple small disabilities affecting the driving task also warrant consideration, investigation and, where justified, specialist referral.
In cases of review assessments requested by the driver licensing authority as a requirement to maintain a conditional licence, the medical history is likely to be well established and the health professional may focus on the recent status of the particular medical condition(s) and the impacts on driving and general functionality.
In cases of assessment as part of an ongoing therapeutic relationship, the medical history is also likely to be well established; however, an exploration of the person’s driving history may be undertaken.
STEP 3: Undertake a clinical examination
In the case of examinations requested by a driver licensing authority, a comprehensive clinical examination will generally be required, involving assessment of functionality of various body systems including physical and cognitive functioning. The examination should focus on determining the risk of the patient’s involvement in a serious motor crash caused by inability to control the vehicle or inability to act and react appropriately to the driving environment.
This publication focuses on common conditions known to affect fitness to drive in the long term (Part B); however, it is not possible to define all clinical situations where an individual’s overall function would compromise public safety. For example, where a person has a systemic disorder or a number of medical conditions, there may be additive or cumulative detrimental effects on judgement and overall function (refer to section 2.2.7 Multiple medical conditions and age-related change).
Additional tests or referral to a specialist may be required if and when clinical examination raises the possibility of potentially significant problems.
In cases of review assessments requested by the driver licensing authority as a requirement to maintain a conditional licence, the clinical examination may focus on the status and management of the particular medical condition(s) while also considering the development of any other medical issues that have developed and may impact on driving and general functionality.
STEP 4: Consider the clinical examination results in conjunction with the patient’s medical history, driving history and driving needs
Upon consideration of the information available, the health professional may draw one of a number of conclusions about the patient’s fitness to drive:
- The person has a temporary condition that may impact on driving ability in the short term but will not affect licence status.
- The person complies with all medical requirements appropriate to the type of licence held or requested.
- The person does not meet the unconditional licensing requirements but medical treatments and/or vehicle or driving modifications may enable them to drive safely under a conditional licence.
- The person does not meet the medical requirements for an unconditional or conditional licence.
- The health professional is in doubt about the patient’s fitness to drive.
Where doubt exists about a patient’s fitness to drive or when the patient’s particular condition or circumstances are not covered precisely by the standards, review by a specialist experienced in the management of the particular condition is warranted. In cases where that specialist may still be uncertain about the relative merits of a particular case, a practical driver assessment is one option that may be appropriate (refer to section 2.3.1 Practical driver assessments). Clearance from the driver licensing authority may be required prior to an assessment taking place. Ultimately, the case may need to be referred to the driver licensing authority for evaluation.
Note: It is the driver licensing authority that is ultimately responsible by law for making the licensing decision. It is sufficient for a professional in such circumstances to prepare a report for the driver licensing authority stating the facts and their opinions clearly.
Where a condition of significance with respect to driving is suspected but not proven (e.g. angina) the health professional should proceed to investigate this. Where there is doubt about the safety of the driver continuing to drive while the condition is being investigated, the patient should be advised accordingly (refer to section 2.2.4 Undifferentiated conditions).
STEP 5: Inform and advise the patient
Health professionals should routinely advise patients about how their condition may impair their ability to drive safely. As part of this process, the patient becomes better informed about the nature of their condition, the extent to which they can maintain control over it, the importance of periodic medical review and the need for regular medication where appropriate.
In the case of temporary conditions that may affect driving ability in the short term, the examining health professional should provide appropriate advice about not driving and should, with the patient’s consent, seek support as required from family members. Notification to the driver licensing authority is not required in such instances.
In the case of an examination requested by a driver licensing authority, the advisory process is straightforward due to the fact that the patient is actively seeking an examination as part of a licence application or renewal, or as a requirement of a conditional licence. They will be expected to return the report to the driver licensing authority in order to complete the licensing process. Should the patient be found not to meet the medical criteria, the health professional will take a conciliatory and supportive role while fully explaining the risks posed by the patient’s condition with respect to driving a vehicle. The health professional should be particularly aware of the needs of the patient whose livelihood is likely to be affected as a result of the assessment findings. There are also special considerations for dealing with individuals who are not regular patients (refer to section 3.3.4 Dealing with individuals who are not regular patients).
The situation may be more challenging when fitness to drive is considered in the course of a patient’s regular treatment and they are found not to meet the medical criteria. In such situations the health professional may be seen by the patient to be making the licensing decision even though this is not the case. Nonetheless, where the health professional believes that continued driving or continued unconditional driving would be likely to be dangerous, the patient should be informed of the risk to him or herself, and to others, of continuing to drive. Where possible, it is helpful to involve a family member or friend in this process. The driver should be encouraged to report their condition voluntarily to the driver licensing authority and should be reminded of their legal obligation to do so.
The standards in this publication should be consulted when dealing with any such situation since they carry an authority that is not imposed on the driver by the health professional but by the national consensus of the driver licensing authorities.
Information brochures may be available from the driver licensing authority to support the patient advisory process (refer to Appendix 9: Driver licensing authority contacts). A range of driver information resources are also listed in section 2.3.4 Information and assistance for drivers.
Where patients are found not to meet the medical criteria or when conditions or restrictions are recommended, advice should be provided regarding alternative means of transport. Reference may also be made to disabled car parking and taxi services (refer to Appendix 6: Disabled car parking and taxi services).
STEP 6: Report to the driver licensing authority as appropriate
In the case of an examination requested by a driver licensing authority, the reporting process involves completing the relevant form provided by the driver licensing authority via the patient. Only information relevant to the patient’s ability to drive should be included in the report, and it should be signed by the examining professional. The original of the medical report should be provided to the patient to return to the driver licensing authority, and a copy should be kept on file in the patient’s medical record. Since the patient generally returns the medical report to the driver licensing authority there is no need for signed consent in this regard. The patient may, however, be asked by the driver licensing authority to provide signed consent for the driver licensing authority to contact the health professional to seek additional information about their condition for the purposes of assessing their fitness to drive.
In the case of assessments made in the course of patient treatment, when encouraging patients to self-report their condition to the driver licensing authority, the health professional should complete a copy of the Medical condition notification form (refer to Appendix 2.2. Medical condition notification form) and provide this to the patient to take to the driver licensing authority. It is recommended that the health professional retain a copy of the Medical condition notification form in the patient record. The driver licensing authority will also accept a letter describing the patient’s condition and the nature of any driving restrictions recommended.
Providing a medical assessment report in an accepted format will reduce the need for the patient to attend on a second occasion for an assessment requested by the driver licensing authority. It will also reduce the time taken by the driver licensing authority to review the case and arrive at a decision regarding the patient’s driver licence status, thus reducing patient stress and uncertainty.
If the health professional is aware that a patient is continuing to drive and is likely to endanger the public, despite the health professional’s advice and despite the driver’s own obligation to report, reasonable measures to minimise that danger will include notification of the driver licensing authority. A copy of the model Medical condition notification form (refer to Appendix 2.2. Medical condition notification form) should be used for this purpose, with additional information provided as deemed necessary by the health professional. The patient should be informed of the health professional’s intent to report (refer to section 3 Roles and responsibilities).
STEP 7: Record keeping
Appropriate records need to be maintained should further information be required by the driver licensing authority. The forms discussed above (refer to section 5.1 Which forms to use) and included in Appendix 2: Forms are designed to assist in this regard.
STEP 8: Follow-up
A health professional has no obligation to contact the patient or driver licensing authority to determine if the patient has reported their condition to the driver licensing authority as advised by the health professional. However, it is appropriate that the health professional, during future patient contacts, enquires about their driving. This is particularly important for public safety in cases where some cognitive deterioration is detected or suspected. If the patient continues to drive despite advice to the contrary, the health professional should consider notifying the driver licensing authority as indicated above.
If the patient did not notify the driver licensing authority and subsequently became involved in a vehicle crash as a result of their condition/ illness, the health professional would not be at risk unless it could be demonstrated that they were aware of the patient’s continuing driving and were also aware of the imminent and serious risk (refer to section 3 Roles and responsibilities).
Help for professionals and vehicle drivers
For guidance regarding fitness to drive contact your state or territory driver licensing authority (refer to Appendix 9 for details). Information is also available from the Austroads website at <www.austroads.com.au>.
References and further reading
- Monash University Accident Research Centre. Influence of chronic illness on crash involvement of motor vehicle drivers, 2nd edition, November 2010. Available: http://monashuniversity.mobi/muarc/reports/muarc300.html.
- Drummer O. The role of drugs in road safety. Australian Prescriber. 2008; 31:33–35.
- Royal Australian College of General Practitioners. Prescribing drugs of dependence in general practice. Available: http://www.racgp.org.au/your-practice/guidelines/drugs-landing/.
- VicRoads, Occupational Therapy Australia. Guidelines for occupational therapy (OT) driver assessors, 2008.
- Dickerson AE. Screening and assessment tools for determining fitness to drive: a review of the literature for the pathways project. Occupational therapy in health care. 2014; 28(2): 82–121.
- Golisz K. Occupational therapy interventions to improve driving performance in older adults: a systematic review. American Journal of Occupational Therapy. 2014; 68: 662–669.
- Unsworth CA, Baker A. Driver rehabilitation: a systematic review of the types and effectiveness of interventions used by occupational therapists to improve on-road fitness-to-drive. Accident Analysis and Prevention. 2014; 71: 106–114.
- Classen S, Brooks J. Driving simulators for occupational therapy screening, assessment, and intervention. Occupational Therapy in Health Care. 2014; 28(2): 154–162.
- Australian Privacy Principles https://www.oaic.gov.au/privacy-law/privacy-act/australian-privacy-principles.