Medical certificates: your responsibilities

• Medical certificates should be supported by clinical findings and documented in the patient records.
• A certificate must clearly show the date it was written, which should be the date you see the patient.
• You can provide a certificate for an illness that began before the date of examination, if appropriate based on your clinical assessment, but do not backdate the issue date of the certificate.
• If you are contacted by a third party (e.g. an employer) and asked to confirm details in a certificate, you can do this but do not elaborate further.

A medical certificate should:

• be legible 
• include your name and your practice address
•  include the name of the patient 
• be dated on the date you examined the patient and issued the certificate 
• identify what you are certifying and the relevant time period.

A medical certificate should always be based on your clinical assessment of the patient, including physical examination where necessary.

You should document your consultation, including findings from your assessment of the patient, in the patient’s medical record. Also keep a copy of the certificate in the patient’s medical record.

Medical condition

A general medical certificate should not include the patient’s medical condition, unless the patient specifically advises they require it. This is to maintain patient confidentiality and privacy.

However, in some situations, such as detailed worker’s compensation claims or government applications for disability support, information such as a diagnosis is required. Sometimes, even in these circumstances, patients will ask you not to specify what illness they have, particularly when it concerns a psychiatric disorder or other personal matter. This is acceptable but it is prudent to advise patients that more information may be requested. If you are pressed for more information and the patient does not consent, you can respond explaining that you do not have patient consent to provide further information. It is then a matter for the patient and the third-party to resolve.

Before providing a certificate to a third party, such as for worker's compensation, you must ensure you have the patient’s consent to disclose the details included in the certificate. If in doubt, you can give the certificate with the completed information to the patient, and they can decide whether to provide it.

In all cases, you should clearly document in the patient’s medical record the condition or diagnosis for which you provided the certificate, as you may be asked to justify your certificate or be required to give evidence to a court, tribunal, board or other authority about the medical certificate and your assessment of the patient. 

Dating the certificate

The certificate should be issued on the day of the examination. You cannot backdate the date you have issued the certificate, as this is inaccurate and implies you examined the patient on a different day.

After careful consideration you may provide a certificate that includes dates that the patient was unwell before the examination. This must be based on your clinical judgement after you have assessed the patient. This should be documented in the patient’s medical record, in addition to keeping a copy of the certificate itself. 

For example, if you examine a patient on 15 May and they have symptoms similar to those they report having the day before the examination, it may be appropriate to provide a certificate stating the patient was unwell and not fit to attend work or school from 14-16 May. However, if the patient reports having symptoms the day prior that you are unable to verify or see any evidence of during the examination, this may not be appropriate.

Similarly, if the patient is seeking a certificate for an illness they say occurred in the previous week, supplying a certificate may not be appropriate. Certificates that purport to confirm an illness or period of incapacity that has resolved before the consultation are a common cause of complaints to regulatory bodies and can result in disciplinary proceedings against the doctor.

If the illness/incapacity started before the examination, but is ongoing, the certificate should be dated the date of your consultation and then separately include the period the patient is unfit for work or school. Based on your judgement this may include dates before your consultation. You may want to change the wording on your certificate from “I have examined xxx” to “Based on the history provided and my examination ...”. In your clinical note of the consultation, you should also make your clinical rationale clear and that your assessment is based on the history provided by the patient and your examination findings. 

Certificates for carer’s leave

You can write a medical certificate if you consider the person cannot work because they need to support or care for a member of their immediate family or household who is sick or injured. The doctor of the person who requires care is best placed to issue a carer’s certificate.

You should only issue a medical certificate where you are satisfied that there is a genuine clinical basis for the person needing time away from work or school.

To help determine this, ask any further questions of the patient and conduct a suitable examination. Document this information in the patient’s medical records to support your decision to issue a medical certificate.

Ensure you remain objective. 

If you are concerned there is an insufficient basis to issue a certificate, you should explain your reasons to the patient and document this in the medical record. Sometimes there might be alternative options, such as issuing a certificate for a shorter period than the patient is requesting and offering to review the patient again if their condition continues.

Intentionally writing a medical certificate with incorrect details, at the request of a patient can result in serious disciplinary action or other legal action.

You may be contacted by a third party, such as a patient’s employer or workplace, and asked to verify the information on a medical certificate. In response, you should:

• confirm the identity of the person making the request
• ask for a copy of the certificate they’ve received 
• confirm if the certificate is genuine and completed by you or not.

You should not provide any other information, unless you have the patient’s consent.

What if a patient alters a certificate?

If it appears that the patient has altered the medical certificate, you may contact the patient and discuss this. Sometimes this can impact your ongoing treating relationship with the patient given the breach of trust.  Each situation will be different. For more information refer to our factsheet about ending the doctor-patient relationship.

Online medical certificate services

The Medical Board of Australia has stipulated that providing medical certificates where you do not speak with patients in real time is not good practice. It is also likely that you will not be covered by your indemnity insurer for this practise. 

If you are participating in an online medical certificate service, you should ensure you can get enough clinical information to be certain there is a sufficient clinical basis for the certificate, and that your patient’s condition is being managed appropriately. This will generally need you to speak with your patient via a telehealth consultation – for more information see our factsheet Telehealth essentials

The Medical Board of Australia’s Good Medical Practice: the code of conduct for doctors in Australia clearly states that, wherever possible, doctors should avoid treating those close to them. This includes close friends, those you work with and family members. Therefore, you should not be in a treating relationship with anyone close to you. It is not appropriate to issue a medical certificate for someone you know, and you should say no, if a family member or friend or someone you work with asks you to provide a medical certificate for them.

If you have any questions about providing a medical certificate, contact Avant.

AMA Guidelines for Medical Practitioners on Certificates Certifying Illness.

Medical Council NSW Medical certificate guideline

Medical Board Australia Good medical practice: a code of conduct for doctors in Australia