Medical certificates and 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.
• If you are contacted by an employer and asked to confirm details provided in a certificate, you can do so but do not elaborate further.
• You can provide a certificate for an illness that began prior to the examination, provided you do not backdate the examination and you have confidence in your medical assessment of the condition.

A medical certificate should:

• be legible
• include your name and your practice address
• clearly state the name of the patient
• avoid medical jargon
• specify the date when the examination took place and the date the certificate was issued
• identify the matter you are certifying and the applicable time period.

The consultation should be recorded in the patient’s medical record.

A medical certificate should always be supported by a thorough and appropriate physical examination where necessary and supporting documentation included in the patient’s medical records. A lack of supporting information and a lack of objectivity may leave you vulnerable to an accusation of unprofessional conduct.

Always keep a copy of any certificate issued in the patient’s medical record in case the contents are ever in dispute.

Diagnosis

A general medical certificate should not include the patient’s diagnosis. This is to protect the patient’s 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 to protect the patient’s confidentiality but it is prudent to warn patients that more information may be required.

Before providing a certificate to a third party, such as for worker's compensation, you must ensure you have the patient’s authority 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 themselves whether to provide it.

Date of examination and dates for sick leave

The certificate should be issued on the day of the examination. You cannot backdate the date you have issued the certificate, implying you examined the patient on a different day.

After careful consideration you may consider providing a certificate to cover a specified time period that the patient was unwell before the examination.

For example, if you examine the patient on 15 May and they have symptoms similar to what they report as having the day prior to the examination it may be appropriate to provide a certificate stating the patient was unwell to attend work 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 assert 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 complaint to regulatory bodies and can result in disciplinary proceedings against the doctor.

If the illness/incapacity started before the examination, the certificate should clearly state the date of your examination and make it clear that your assessment is based on the history provided by the patient and your examination findings.

You must remain objective in your comments and findings. Do not fall into the role of “taking the patient’s side” in any dispute.

Requirements 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. Only the doctor of the person who requires care should issue a carer’s certificate.

What if you consider issuing a medical certificate to be inappropriate?

Following assessment of the patient’s medical condition you may consider the issuing of a medical certificate inappropriate. In this situation you will need to carefully explain your reasons to the patient and carefully document the conversation in the medical record.

To be reasonably satisfied that the illness/incapacity is genuine, ask questions and conduct a suitable examination and record this information in the patient’s medical records to support any certificate issued. If you believe there is no evidence of illness and you do not wish to provide a certificate record this in the patient’s file, outlining the history and results of the examination as well as summarising the explanation to the patient of why no certificate can be issued.

Do not recommend an unreasonable length of absence in a certificate, especially if it is suggested the patient wants to use up sick leave entitlements. You should objectively assess the patient before issuing a medical certificate. It may be more appropriate to write a certificate for a limited period of time and offer to review the patient again if incapacity or illness is persisting.

Doctors can be an easy target for unscrupulous patients in such matters because they expect patients to tell the truth. Regardless of the patient's motives, you should consider whether it is reasonable to issue a certificate based on the information given and your objective assessment of the patient’s condition. Your clinical record should be able to provide evidence to support your decision.

Conspiring with a patient to obtain a benefit through a medical certificate can result in serious disciplinary action or other legal action.

You should refuse any request for a certificate unless you are satisfied that the illness or incapacity is genuine based on the information provided by the patient and your objective assessment of the patient’s condition.

Verifying a medical certificate

If you are contacted by a third party (such as an employer) and asked to verify the information on a medical certificate you should:

• verify the identity of the person making the request
• ask to see a copy of the certificate in question
• confirm if the certificate is genuine and completed by you or not.

No other information should be given without express patient consent.

What if a patient alters a certificate?

If during the verification process it is apparent that the patient has altered the medical certificate you will need to consider your ongoing relationship with the patient following the breach of trust. Each situation will need to be considered on an individual basis. If you decide to terminate the doctor-patient relationship advice can be found here.

If you are issuing a medical certificate for a particular legal purpose (for example, in support of a patient’s application for benefits), you should ensure you are familiar with your legal obligations under the relevant rules and legislation.

You may not be able to meet your professional, legal and ethical obligations if you participate in an online medical certificate service. In any situation where you cannot conduct a face-to-face consultation with a patient seeking a certificate we would advise caution.

In some circumstances, however, such as a remote area, a tele-health consultation would be appropriate.

Be very cautious when a family member or friend requests a medical certificate from you. 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.

Clearly record the diagnosis that formed the basis of the medical certificate in your clinical notes. You could 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.

AMA Guidelines for Medical Practitioners on Certificates Certifying Illness

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

For medico-legal advice, please contact us here, or call 1800 128 268, 24/7 in emergencies.