Summary Guide.
Medical certificates must be supported by clinical data and documented in medical histories.
The certificate must clearly indicate the date it was written.
If you are contacted by your employer and asked to verify the information on the certificate, you may do so, but do not go into detail.
You can provide a certificate of illness that began before the examination, as long as you are not conducting the examination retroactively and are confident in your medical evaluation of the condition.
Legislative requirements for a medical certificate
The medical certificate must:
Be legible.
Include your name and address of your practice
Clearly state the patient’s name
Avoid medical jargon
Include the date of the exam and the date the certificate was issued
state the issue you are certifying and the applicable time period.
The consultation should be recorded in the patient’s medical record.
The medical certificate must always be supported by a thorough and proper physical examination, where appropriate, and supporting documentation included in the patient’s medical record. Lack of supporting information and lack of objectivity can make you vulnerable to charges of unprofessional conduct.
Always keep a copy of any certificate issued in the patient’s medical record in case its contents ever become questionable.
Diagnosis
A general medical certificate should not contain the patient’s diagnosis. This is necessary to protect the patient’s privacy.
However, in some situations, such as a detailed workers’ compensation claim or a government claim for disability benefits, information such as a diagnosis is required. Sometimes, even in these circumstances, patients will ask you not to specify what their condition is, especially when it involves a mental disorder or other personal matter. This is acceptable to protect patient confidentiality, but it is prudent to warn patients that additional information may be required.
Before you provide the certificate to a third party, such as workers’ compensation, you should make sure that you have the patient’s authority to disclose the information included in the certificate. If in doubt, you can give the certificate with the completed information to the patient and he or she will decide whether to provide it.
Date of examination and dates of sick leave
The certificate must be given on the day of the exam. You cannot date the certificate retroactively, implying that you examined the patient on a different day.
After careful consideration, you may consider issuing a certificate covering a certain period of time when the patient was unwell prior to the examination.
For example, if you examine the patient on May 15 and he or she has symptoms similar to the day before the examination, it may be appropriate to provide a certificate that the patient was unwell to go to work on May 14-16. However, if the patient reports symptoms the day before that you can’t check or see at the time of the exam, it may not be appropriate.
Likewise, if the patient requests a certificate for an illness that he or she claims to have had the previous week, it may not be appropriate to provide the certificate. Certificates that are supposed to verify an illness or period of disability that was eliminated prior to the consultation are a frequent cause for complaints to regulatory agencies and may result in disciplinary proceedings against the physician.
If the illness/disability began before the examination, the certificate should clearly state the date of your examination and clearly state that your evaluation is based on the history provided by the patient and the results of your examination.
You must remain objective in your comments and conclusions. Do not fall into the role of “taking the patient’s side” in any dispute.
Requirements for Caregiver Leave
You can issue a medical certificate if you believe that a person cannot work because they need to support or care for a family member or household member who is ill or injured. The care certificate should only be issued by the doctor of the person who needs care.