Guidelines for issuing a medical certificate
Issuing of Medical certificates is an integral responsibility of a medical professional. Quite often, it is casually issued leading to its gross misuse amounting to even being considered as false certificate. Moreover, it indirectly violates the medical ethics and is liable to be punished severely may be entail the cancellation of the registration to practise of the medical professional.
Seeing the importance of the subject, Delhi Medical council has shown concern about the recent increase of cases, whereby a medical certificate has been issued, which does not corroborate with the medical illness and many of such cases have been submitted the court of law, where the authenticity of such certificate has been doubted, being further referred to the council by the court to initiate action against them.
Dr Arun Gupta, President, Delhi Medical Council, released the DMC guidelines for issuing certificate and requested all the doctors to strictly follow the same, while issuing a medical certificate and save themselves of unnecessary harassment and punishment. The guidelines are as follows :-
(a) Medical certificates are legal documents. Medical practitioners who deliberately issue a false, misleading or inaccuratecertificate could face disciplinary action under the Indian Medical Council (Professional Conduct, Etiquette and Ethics), Regulations, 2002. 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.
It is, therefore, a misnomer to state that medical certificate is “not valid for legal or Court purposes”, and should be avoided. Registered medical practitioners are legally responsible for their statements and signing a false certificate may result in a registered medical practitioner facing a charge of negligence or fraud.
(b) The certificate should be legible, written on the doctor’s letterhead and should not contain abbreviations or medicaljargon. The certificate should be based on facts known to the doctor. The certificate may include information provided by the patients but any medical statements must be based upon the doctor’s own observations or must indicate the factual basis of those statements. The Certificate should only be issued in respect of an illness or injury observed by the doctor or reported by the patient and deemed to be true by the doctor.
The certificate should:-
When issuing a sickness certificate, doctors should consider whether or not an injured or partially incapacitated patient could return to work with altered duties.
The medical certificate under normal circumstances, as a rule, should be prospective in nature i.e. it may specify the anticipated period of absence from duty necessitated because of the ailment of the patient. However, 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 certificatecertifying 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 should add supplementary remarks, where appropriate, to explain the circumstances which warranted the issuances of certificate retrospective in nature.
(c) It is further observed that under no circumstances, a medical certificate should certify period of absence from duty, for a duration of more than 15 days. In case the medical condition of the patient is of such a nature that it may require further absence from duty, then in such case a fresh medical certificate may be issued.
(d) Record of issuing medical certificate-Documentation should include:
An official serially numbered certificate should be utilized. The original medical certificate is given to the patient to provide the documentary evidence for the employer. The duplicate copy will remain in the Medical Certificate book for records. The records of medical certificate are to be retained with the doctor for a period of 3 years from the date of issue.
Seeing the importance of the subject, Delhi Medical council has shown concern about the recent increase of cases, whereby a medical certificate has been issued, which does not corroborate with the medical illness and many of such cases have been submitted the court of law, where the authenticity of such certificate has been doubted, being further referred to the council by the court to initiate action against them.
Dr Arun Gupta, President, Delhi Medical Council, released the DMC guidelines for issuing certificate and requested all the doctors to strictly follow the same, while issuing a medical certificate and save themselves of unnecessary harassment and punishment. The guidelines are as follows :-
Guidelines for issuing a Medical Certificate
(a) Medical certificates are legal documents. Medical practitioners who deliberately issue a false, misleading or inaccuratecertificate could face disciplinary action under the Indian Medical Council (Professional Conduct, Etiquette and Ethics), Regulations, 2002. 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.
It is, therefore, a misnomer to state that medical certificate is “not valid for legal or Court purposes”, and should be avoided. Registered medical practitioners are legally responsible for their statements and signing a false certificate may result in a registered medical practitioner facing a charge of negligence or fraud.
(b) The certificate should be legible, written on the doctor’s letterhead and should not contain abbreviations or medicaljargon. The certificate should be based on facts known to the doctor. The certificate may include information provided by the patients but any medical statements must be based upon the doctor’s own observations or must indicate the factual basis of those statements. The Certificate should only be issued in respect of an illness or injury observed by the doctor or reported by the patient and deemed to be true by the doctor.
The certificate should:-
- Indicate the date on which the examination took place
- Indicate the degree of incapacity of the patient as appropriate
- Indicate the date on which the doctor considers the patient is likely to be able to return to work
- Be addressed to the party requiring the certificateas evidence of illness e.g. employer, insurer, magistrate
- Indicate the date the Certificatewas written and signed.
- Name, signature, qualifications and registered number of the consulting Registered MedicalPractitioner.
- The nature and probable duration of the illness should also be specified. This certificatemust be accompanied by a brief resume of the case giving the nature of the illness, its symptoms, causes and duration.
When issuing a sickness certificate, doctors should consider whether or not an injured or partially incapacitated patient could return to work with altered duties.
The medical certificate under normal circumstances, as a rule, should be prospective in nature i.e. it may specify the anticipated period of absence from duty necessitated because of the ailment of the patient. However, 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 certificatecertifying 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 should add supplementary remarks, where appropriate, to explain the circumstances which warranted the issuances of certificate retrospective in nature.
(c) It is further observed that under no circumstances, a medical certificate should certify period of absence from duty, for a duration of more than 15 days. In case the medical condition of the patient is of such a nature that it may require further absence from duty, then in such case a fresh medical certificate may be issued.
(d) Record of issuing medical certificate-Documentation should include:
- Patient to put signature/ thumb impression on the medicalcertificate
- Identification marks to be mentioned on medicalcertificate
- That a medicalcertificate has been issued
- The date/ time range covered by the medicalcertificate
- The level of incapacity (i.e. unfit for work, light duties, etc within scope of practice)
- Signature/ thumb impression of patient
An official serially numbered certificate should be utilized. The original medical certificate is given to the patient to provide the documentary evidence for the employer. The duplicate copy will remain in the Medical Certificate book for records. The records of medical certificate are to be retained with the doctor for a period of 3 years from the date of issue.
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