Articles and Case Studies

Tips for writing medical certificates

09 Dec 2020

Julian Walter 110x137

by Dr Julian Walter

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Medical certificates can lead to complaints by patients and those receiving the certificate (e.g. employers, courts, education facilities). Whether to issue a certificate, or what to say, can pose challenging dilemmas.

The Medical Board has high expectations of practitioners who issue certificates, as stated in the Code of Conduct (at 10.9):


10.9 Medical reports, certificates and giving evidence:
The community places a great deal of trust in doctors. Consequently, doctors have been given the authority to sign a variety of documents, such as a medical certificate of cause of death (death certificates) and sickness certificates, on the assumption they will only sign statements that they know, or reasonably believe, to be true. Good medical practice involves:

  • 10.9.1: Being honest and not misleading when writing reports and certificates, and only signing documents you believe to be accurate.
  • 10.9.2: Taking reasonable steps to verify the content before you sign a report or certificate, and not omitting relevant information deliberately.
  • 10.9.3: Preparing or signing documents and reports if you have agreed to do so, within a reasonable and justifiable timeframe.
  • 10.9.4: Making clear the limits of your knowledge and not giving opinion beyond those limits when providing evidence.

When should I avoid issuing a certificate?

You must reasonably believe that the certificate you’re issuing is accurate and not misleading. In some circumstances, saying ‘no’ to the request will be appropriate, despite the patient’s protests.

You should decline issuing a certificate in situations where you’re concerned about the accuracy of the information (e.g. insufficient evidence of illness, concern about veracity of the information) or where the request is outside the scope of your care or expertise.

Managing a refusal to provide a certificate can be challenging, as it represents a conflict between your role in supporting your patient and your professional obligation of accuracy. You can seek advice from our Medico-legal Advisory Service if you feel uncomfortable about providing a certificate.

Do not issue a certificate for yourself, and avoid issuing a certificate for close friends and family. Where issuing a certificate, you should have consulted with the patient and made an entry in the records.

Remember that medical certificates are legal documents, and you may be required to give evidence about a certificate you have issued. Signing a false or misleading certificate can result in disciplinary consequences and legal action.

What should I record on the certificate?

The certificate should not be addressed ‘To whom it may concern’ as this poses the risk of it being used for a different purpose to what you had expected. Address it to the intended audience – even if it’s just ‘Dear Court’, ‘Dear Workplace, or ‘Dear University’.

Certificates should be written in layperson’s language. Include your name and address, and the name of the patient. Consider including whether the patient should be absent from the activity, or is able to attend in a reduced capacity.

Generally, a medical certificate should not reveal a diagnosis, unless the patient consents to this. However, a patient’s partial consent cannot justify the issuing of a misleading certificate or missing critical information. There are circumstances (e.g. workplace health and safety) where clinical information is required – however, the patient must still consent, otherwise you risk breaching patient trust and confidentiality.

Any dispute over how much clinical information needs to be included, in the absence of patient consent, is between the patient and the party they are presenting the certificate to. Avoid the provision of employment advice (e.g. commenting on the employers’ right to request information) – this should be sought externally by the patient.

Where providing clinical information (with consent), indicate the source of the information (e.g. “The patient discussed…”; “My examination revealed…”; “Review of records…”).

How should I date a certificate?

A certificate should be dated and signed on the day the certificate was issued – the ‘issue date’ should never be backdated. The certificate may also refer to several other dates, if these are different to the issuing date (e.g. the consultation date; the date of the illness as stated by the patient; the dates the patient is off work). 

Care should be taken in deciding to issue a certificate covering a historic time period, where the initial consultation occurs significantly after the illness. In this case, you may need to explain the difference between the date of illness, consultation date and certificate issue date. A letter of support may be more appropriate.

What consultation notes should I capture?

As doctors, we’re not just a mouthpiece for the patient’s claim. In circumstances of subjective illness (e.g. mental health concerns), we have a professional responsibility to consider the clinical issues relevant to the patient’s presentation, and to make reasonable enquiries to verify information and the accuracy of the certificate.

You are still obliged to take a history and relevant examination – and this information should be captured in the records. The Board may consider your records and consultation if a complaint is made about the certificate.

  • What are the events leading up to the event requiring certification?
  • Are the symptoms serious enough to require follow-up or referral?
  • Is the patient at risk?
  • Have you recorded basic observations and a relevant physical examination (e.g. that ‘gastro’ might just be the beginning of appendicitis)?
  • Have you considered objective tests and other investigations (e.g. K10 for mental health concerns)?
  • What safety-net advice have you provided?

What if I can’t issue a certificate?

You may be able to issue a ‘letter of support’ – ideally label the document as such and refer to not being able to certify a condition. This is a document that seeks the favourable consideration of the patient’s request and may discuss their credibility. With consent, you can include indirect supportive information. While letters of support often just reiterate the patient’s request, without you being able to objectively add to the situation, they may still be of assistance.

What should I consider when certifying fitness?

These requests can be complex and may require specific advice. It’s much simpler to certify (with consent) the presence of pathology, or specific negative findings, than attesting in an open-ended fashion to a patient’s general fitness. Consider carefully what you’re being asked to certify, as there’s a risk that certifying fitness transfers legal risk to the practitioner. Also consider that it may not be possible to provide the requested certification.

Some requests require information not available to the doctor (e.g. what fitness standard is relevant; what a role entails, inability to simulate the required activities). Other requests will be outside the expertise of the doctor. Any limitations to your certificate should be noted.

You could decline to follow the requested wording, choosing only what information you can provide. It can be helpful to refer to accepted standards and whether the patient met them. Use of double negatives may assist in meeting the request – e.g. “There is no evidence that the patient is unfit to return to work” – as this avoids certifying fitness. Recommendations as to further testing may be helpful.

 

Read more icon

Exercise caution: fitness certificates and medico-legal risks
mdanational.com.au/advice-and-support/library/articles-and-case-studies/2013/12/exercise-caution-fitness-certificates-and-medico-legal-risks

 

Sample medical certificates

Certificate issued for historic period with differing consultation and issue dates

[Issue date]

Dear Workplace

Jill was seen on 20 December 2020, for a medical condition requiring time off work between 16-19 December 2020 inclusive.


Certificate with consent

Dear Workplace

The following has been provided with Jack’s consent. He will be off work from 1-3 January 2021, following surgery for appendicitis on 26 December 2020. After this, he would be able to return to a role with no lifting or more than gentle ambulation for two weeks, and may require reduced hours based on discomfort from prolonged sitting. Further guidance can be provided at that time.


Letter of support

Dear University

Jill has been my patient for 10 years and has requested this letter of support. She informs me she was unwell in January for two weeks and unable to sit for her exams. I did not review Jill at the time, so I cannot issue a medical certificate. Jill does have a known significant illness and has required certificates for time off for similar past episodes. Could you consider this information in deciding whether to grant Jill an exam re-sit?


Fitness certificate

Dear Workplace

Jack does not meet the current [date] Commonwealth Department of Health [link] guidelines for a suspected COVID-19 case, and there is no current indication for further testing. I can find no reason why he should not return to work.

 

Dear Gym

Other than mild asthma, Jill is not known to have other significant illnesses. She had a negative stress test in 2015 and has a normal blood pressure, BMI, and resting pulse. Based on the history, examination, and investigations, I can find nothing that would preclude Jill from joining the gym. I can arrange referral (e.g. exercise physiologist) if a more specific assessment is required.


 



Communication with Patients, Confidentiality and Privacy, Complaints and Adverse Events, Medical Records and Reports, Practice Management, Emergency Medicine, General Practice, Practice Manager Or Owner, Sports Medicine, Physician
 

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