Medical certificate under Ahpra’s scrutiny

Writing a medical certificate may be an everyday occurrence for doctors, but it isn’t always a simple matter. There has been an increased willingness by employers of patients to make complaints against doctors in relation to the provision of medical certificates, as a GP member* found.

A patient presented to his treating doctor requesting a medical certificate for time off work in relation to workplace stress and anxiety. The patient’s work-related anxiety had increased over time following an interaction with his manager some eight months earlier.

The doctor assessed the patient and wrote a medical certificate, providing personal leave from work. Since the patient was already on annual leave, and was not due back for another fortnight, the doctor dated the certificate two weeks in advance so it would commence when the patient was due to return to work.

When the patient later decided to make a WorkCover claim in relation to his work-related anxiety, the doctor was asked to fill in a standard WorkCover certificate which required further details, including a specific date on which the patient first suffered the ‘injury’. As the patient’s mental health had deteriorated over time, the doctor considered the original ‘injury’ to be the incident between the patient and his manager some eight months earlier.

Date discrepancy

Both certificates were completed with due diligence, but one required a date the patient was unfit for work, and the other required the specific date of the ‘injury’. The patient’s employer noted the discrepancy in the dates and made a complaint to the regulator.

Ahpra contacted the doctor wanting to know why the medical certificate was post-dated and why it had a different date to the WorkCover certificate.

Board notes doctor’s self-reflection

In responding to the complaint, the doctor highlighted the difference in the specific questions posed by the two certificates and noted the information he provided when completing all forms was accurate and honest. He further explained that in completing both certificates he had given as much information as he could, he had not withheld information, nor had he provided deliberately false or misleading information.

The doctor acknowledged that upon reflection, the date on the medical certificate should have been the date he examined the patient and considered him unfit for work, not the date he considered the patient required additional leave from work. He apologised and reassured the Medical Board he would not repeat this.

The Medical Board took into account the doctor’s honesty and self-reflection and decided to take no further action.

Key lessons

It is important that doctors give proper consideration to what they are certifying when providing a medical certificate, and as always, ensure that it is supported by good record keeping.

• The Medical Board of Australia’s Good medical practice: a code of conduct for doctors in Australia states a practitioner should only sign a document they know or reasonably believe to be true. In practice, this means you need to verify information presented by the patient and in some cases, it might be prudent to refuse to write a medical certificate.
• A consultation should occur if you are writing a medical certificate for a patient as a conversation, and clinical examination where necessary, should take place to inform what is provided in the certificate. Ensure you are thorough in your notetaking and can show clinical justification for your conclusions. It’s important that you include all relevant information and be as accurate as possible.

Medical certificate guidelines

• The AMA Guidelines on Medical Certificates specify that a diagnosis does not need to be included in a medical certificate. The only details required are confirmation you have examined the patient and the dates you consider the patient unfit. Be mindful of your privacy obligations, especially if asked for confirmation from a third party. Any other details should be kept in the patient’s medical record.
• Medical certificates should be written on the day of examination, not back-dated or post-dated. When considering how long to provide the certificate for, consider clinical guidelines and document the clinical justification in the patient’s medical notes.
• A lack of supporting information and a lack of objectivity may leave you vulnerable to an accusation of unprofessional conduct. If a certificate is not warranted, then document in the clinical notes the explanation given to the patient as to why.
• Clearly record the diagnosis or clinical findings that formed the basis of the medical certificate in your clinical notes. You may be asked to give evidence to a court, tribunal, board or other authority, about the medical certificate and your assessment of the patient.
• If you are issuing a medical certificate for a legal purpose, such as in support of a patient’s application for benefits, ensure you are familiar with your legal obligations under the relevant rules and legislation.

Useful resources

• Guidance about completing medical certificates can be found in Section 10.9 of the Medical Board of Australia’s Good medical practice: a code of conduct for doctors in Australia and in our factsheet, Medical certificates and your responsibilities.
• If you have concerns about completing a medical certificate, email us on nca@avant.org.au or call 1800 128 268, available 24/7 in emergencies.
• *The case in this article is based on Avant claims experience to date. Certain information has been de-identified to preserve privacy and confidentiality.