Guidelines for Medical Practitioners on Certificates Certifying Illness - 2011

25/03/2011

1.   Preamble

1.1  The basis of the doctor-patient relationship is trust and confidentiality. Doctors trust their patients and protect their right to confidentiality. Patients trust their doctors regarding medical care and expect confidentiality. Doctors are not the agents of employers, private industry, or governments.

1.2  A certificate certifying illness may be issued where a patient's state of health necessitates time away from the work-place, school, or other relevant activities (in this guideline, the workplace is used as the primary example). This may be because the patient cannot attend or should not attend their workplace, school, or other relevant activities. Another certificate may be required for carer’s leave entitlement.

2.    Purpose

2.1  The purpose of this guideline is to clarify the responsibilities of medical practitioners, patients (eg., employees), and relevant third parties (eg., employers) regarding certificates certifying illness ("sickness certificates") within the context of the doctor-patient relationship.

3.    Application

3.1  This guideline is not intended to apply to workers compensation schemes, life insurance, accident compensation, superannuation, or other legislative schemes that have their own regulatory mechanisms. It is confined to certification of illness for purposes of sick leave and with applications for carer’s leave. The general principles regarding procedures dealing with confidentiality apply to all medical certificates.

4.    The Responsibilities of Medical Practitioners

4.1  Medical certificates are legal documents. Medical Practitioners who deliberately issue a false, misleading or inaccurate certificate could face disciplinary action under the Health Practitioner Regulation National Law. Medical practitioners may also expose themselves to civil or criminal legal action. Medical practitioners can assist their patients by displaying a notice to this effect in their waiting rooms.

4.2  Employers may, in reasonable circumstances, seek further information from the medical practitioner who issued a certificate. Before providing any further information to the employer, the medical practitioner should verify the employer’s identity and obtain express consent from the patient before disclosure of the further relevant information to their employer.

4.3  Where an employer contacts the medical practitioner to verify the veracity of a sickness certificate (eg., to determine if it’s fraudulent in any way), the medical practitioner should verify the employer’s identity and confirm the veracity of the certificate. The doctor should not provide any other information about the patient without the patient’s express consent.

4.4  The doctor may decline to provide a certificate if he or she feels it is inappropriate to do so.

5.    The Responsibilities of Patients

5.1  Patients have a responsibility to consult their medical practitioner in a timely manner when requesting a sickness certificate. Patients also have a responsibility to present the reasons for requesting a certificate in a way that enables the doctor to make an accurate assessment of their eligibility for a certificate.

5.2  At the time the certificate is issued, it is the responsibility of the patient to ensure that the employer's requirements for leave have been met.

5.3  Patients must not alter the certificate in any way.

6.   The Responsibilities of Employers

6.1  Employers should recognise the right of their employees to keep details of their medical condition confidential. Employers should not expect to see a diagnosis on the certificate. Employers should also recognise that the certification by the medical practitioner of an employee's unfitness for work is sufficient.

6.2  The employer has a responsibility to inform the employee of the requirements for sick leave.

7.   Certificate Requirements

7.1  The usual requirements for a sickness certificate are:

7.1.1 Name and address of the medical practitioner issuing the certificate;

7.1.2 Name of the patient;

7.1.3 Date on which the examination took place;

7.1.4 Date on which the certificate was issued;

7.1.5 Date(s) on which the patient is or was unfit for attendance;

7.1.6 Supplementary information of assistance to the patient in obtaining the appropriate leave especially where there is a discrepancy in the period for which the certificate is issued and the date of the certificate.

7.2  A diagnosis is not usually required. If it is a legal requirement for a diagnosis to be provided medical practitioners should inform the patient if they have written their diagnosis on the certificate and only proceed following the express consent of the patient.

7.3  The certificate should be legible and written so that a non-medical person is able to read and understand it (eg., avoiding unnecessary abbreviations and medical jargon). The certificate should be written on stationery designed specifically for this purpose.

7.4  Medical practitioners have a responsibility to obtain and note sufficient factual information through history and examination to issue a sickness certificate.

8.   Date of Certificate

8.1  Certificates must be dated on the day on which they were written. Under no circumstances can this be breached.

8.2  There may be medical conditions which enable the medical practitioner to certify that a period of illness occurred prior to the date of examination. Medical practitioners need to give careful consideration to the circumstances before issuing a certificate certifying a period of illness prior to the date of examination, particularly in relation to patients with a minor short illness which is not demonstrable on the day of examination and add supplementary remarks, where appropriate, to explain any discrepancy.

8.3  Medical practitioners should be clear that their assessment of the patient is based on the patient’s history and the findings of the examination. The certificate may include information provided by the patient but the medical practitioner’s assessment should be based on illness or injury observed by the medical practitioner or reported by the patient and deemed to be true by the medical practitioner.

8.4  Medical practitioners should retain a copy of a patient’s sickness certificate.

9.   When a sickness certificate should not be provided

9.1  A certificate should not be provided where a doctor believes that there is insufficient evidence of disability.

9.2  Wherever possible, doctors should avoid issuing sickness certificates to anyone with whom they have a close personal relationship.

10.   Certificates for carers’ leave

10.1  Only the patient’s treating doctor should issue a carer’s certificate. Carer’s certificates should only be issued with the consent of the patient.

10.2  It is not the treating doctor’s responsibility to determine who may qualify as a carer.

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