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Learn the principles and guidelines for writing various certificates, including medical certificates, sickness certificates, precautions to consider, and guidelines for medical practitioners. Understand the importance of accurate information in certificates.
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SKILL • ABILITY TO DO SOMETHING
Certificates • An official document that gives details to show that something is true • Issued from an official capacity • Documentary evidence • Medical certificates and medico legal report • Sickness , fitness, death, injury ,drunkenness, age, impotency, rape, insanity. etc
GENERAL PRINCIPLE FOR WRITING CERTIFCATES Preamble Body Conclusion
Preamble contains Name ,address ,identity of patient-age –sex-identification mark or signature Place and date of examination Name and designation of doctor
Body Case history or diagnosis after physical examination and laboratory investigation
Conclusion Doctors inference and opinion after diagnosis,laboratery investigation or other findings With name, qualification, register number signature, official seal.
MEDICAL CERTIFICATES It is document issued by a registered medical practitioner regarding ill heath, insanity or death of a patient Medical certificates are documents containing health and disability related information SICKNESS CERTIFICATES Stating about sickness or ill health
MEDICAL CERTIFICATES Simplest type of written medical evidence Certificates which are issued by the medical officer at request of patient or relatives, in one of the following situation. • Sickness • Fitness • Vaccination • Compensation (disability certificates) • Birth • Death
PRECAUTIONS Precaution to be taken by a medical officer while issuing, medical certificate are: • Medical certificate can only be issued by RMP & should carry his signature, name, designation and registration number • In all certificates name, age ,sex, address, and two marks of identification of the patient should be written. [ practically signature, left thumb impression, scars, and moles or tattoo marks on exposed part of the body are written.
Certificates should be always based on observation and never on history alone, and they can be used as evidence. Issuing false certificates is punishable under section 197 of IPC. • The MO should never keep the blank prescription and certificates, signed in advance. • A copy of certificate issued should be retained by the M.O.
The certificate should de complete and therefore mention necessary details. E.g. A) In sickness certificate - exact nature of illness B) In fitness certificate- nature of illness from which he was suffering, Duration of suffering, that he is now fit to resume his duty (mention his occupation)
C) Vaccination certificate- name of vaccine, Batch number of vaccine, Date of vaccination. D) Disability certificate-Nature of disability, Cause of disability,% of disability, whether disability is temporary or permanent. E) Birth certificate- Name of Mother, Date and Time of birth, Place of birth
Guidelines for Medical Practitionersregarding the issue of Medical Certificates Doctors are legally entitled to issue Medical Certificates. Utmost care must be taken in writing Medical Certificates, as they are very often legal documents and may be challenged.
When writing a Medical Certificate, the need to state the true health condition of the patient must be the primary concern. Therefore, the doctor is expected to state the truth, which may, at times be in conflict with other interests of the patient, which is of no concern to the doctor.
Medical Certificates are confidential documents and should be handed over to the patient personally or delivered to the relevant authority that requires it. In certain circumstances, a Medical Certificate may be required by a third party, and the doctor may issue it if it appears to be appropriate.
Doctors are advised to keep a record or a copy of the certificate for future reference. It should be ensured that a Medical Certificate issued for one purpose will not be used for another. e.g.. a Medical Certificate for an illness recommending absence from workshould not be produced in courts. This must be clearly stated in the certificate and told to the patient.
Medical Certificates are requiredfor the following purposes: Absence from place of work or school due to illness or injury Certificates of Fitness For employment, scholarship abroad, driving licence, etc. – issued to the employer/ scholarship awarding institution/ licensing authority, etc.;
To Courts – to be excused from attending courts due to illness or injury or On the order of a Magistrate or Judge regarding fitness to attend, when a person does not attend courts citing medical reasons.
To be exempted from performing certain functions, such as sitting for an examination, engaging in work that requires much exertion, disability due to illness or injury preventing a person from attending to some aspects of his job requirements, etc.
Insurance purposes (a) On the request of the Insurer, to assess the suitability of acceptance for insurance. (b) To submit a claim to recover an insurance award.
Disability Certificate for compensation, etc. Provident Fund – When medically condemned, retirement on medical grounds
Certificates relating to medical cause of death of a person – e.g. for insurance purpose – Accident/ Homicide/ Natural ( not paid if Suicide), Stomach contents – smelling of liquor in accidental death ( Road Traffic Accident or otherwise)
Miscellaneous Certification of testamentary capacity The true mental state of the person should be stated and the doctor should not be a beneficiary, either directly or indirectly.
A Medical Certificate for a person with an illness should be written by the doctor who is treating him/her. The doctor should correctly identify the patient, by checking the identity card ifnecessary. The doctor should assess the patient's condition and decide on the period of rest the patient requires in order recovering from the illness.
The period should not depend on the patient's request. The rules of the employer should be followed when issuing medical certificates. In Government Service, the period of leave granted should not exceed one month at a time, up to two months, and thereafter for two weeks at a time for a further one month, unless there are Circulars or instructions that have to be followed – eg. Maternity leave,recommendations of Medical Boards for patients with tuberculosis etc.
If a person requires leave in excess of three months, a medical board has to be recommended. Leave exceeding two weeks granted to a public servant can only be recommended by a Government Medical Officer. Backdating leave should not exceed three days, except in the case of an ‘indoor' patient, and the practitioner should be able to justify such leave considering the nature of the illnesses
In every instance the minimum period of leave required should be recommended. The Medical Certificate should carry the full name of the patient, age, sex, address , the nature of the illness , whether fit for duty or not and the recommended leave . The doctor should sign the Medical Certificate and clearly write the Name, Qualifications registered in the SMC, the SMC Registration Number, Official Designation, the address and the date. It would be preferable to have a rubber stamp for the purpose.
Sickness Certificate to be produced in a Court of Law for excusing a person from attending courts The Practitioner should exercise utmost care in issuing such a certificate. The time and date of examination should be stated and the recommendation should not be backdated A comprehensive record of the patient's condition and the practitioner's findings should be maintained and secured. • The period the person is not fit to attend courts and the date on which the person is likely to recover and be fit to attend courts must be stated • The diagnosis or the nature of the illness should be stated.
If it appears to the doctor that the patient has attempted to avoid attending courts by resorting to various reasons, and later requests a certificate, that fact has to be revealed to the courts. For example, a patient may request a form of treatment or a surgical procedure, which may not be urgent, without divulging the need to attend courts, and request a certificate seeking to excuse him from attending courts. It may turn out that the procedure resulted in the patient being unfit to attend courts.
Similarly, the doctor must ensure that the patient is not attempting to evade attending courts by submitting a medical certificate or trying to getundue advantage or sympathy. The doctor should never be a party, directly or indirectly to such an attempt.
The doctor must be well aware of his obligation to the patient as well as his responsibility to the court for administration of natural justice. The Court may request a Second Opinion about a medical certificate from another doctor. That Doctor must act on his own convictions and not be biased by the earlier certificate, whatever position such doctor holds.
Medical Certificates for Insurance purposes When a doctor issues a certificate or fills a form for a person who seeks to join an Insurance scheme, the doctor should divulge correct and accurate information, even if the person may not be benefited as a result.
Certificates for Insurance claims may be either for recovery of expenses in obtaining health care, or for insurance benefits to family members when the insured person dies. In the latter instance, the doctor should ensure that the certificate is handed over to the proper legal claimant. It should be borne in mind that such certificates may be challenged in courts and hence extra caution should be exercised in issuing such certificates.
If the cause of death of the patient was aggravated by certain habits of the patient, (eg. alcohol consumption), such facts should be divulged even if it affects the claim made by the beneficiaries.
MEDICAL CERTIFICATE FOR LEAVE OR EXTENSION OF LEAVE Signature of applicant I Dr. ------------------------------------------after careful examination of the case hereby certify that ------------------------aged ------------------sex-------------------------resident of --------------------------------, who’s signature is given above is suffering from--------------------and I consider that a period of absence from duty of -----------------days with effect from----------------is absolutely necessary for restoration of his health. • Identification marks • 1---------------------- • 2-------------------- • Place Signature, name & stamp of Dr • Date Register number • Time
MEDICAL CERTIFICATES OF FITNESS TO RETURN TO DUTY Signature of applicant I Dr---------------------------------------do here by certify that I have carefully examined -----------------------------------------------of the department-------------------------------------------------------who’s signature is given above and find that he has recovered from his illness -----------------------------with which he was suffering since--------and is now fit to resume his duties in Govt.service w.e.f. ---------------.I also certify that before arriving at this decision I have examined the original medical certificates and statement of the case on which leave was granted or extended and have taken these in to consideration in arriving at my decision. • Identification marks 1---------------------- 2-------------------- Place Signature, name & stamp of Dr Date Register number Time
What constitutes a 'valid' medical certificate? A practitioner shall only grant a certificate of illness, certificate contains the following information, namely:
(a) the name, address and qualification of the practitioner (b) the name of the patient (c) the employment details of the patient (if applicable) (d) the date and time of the examination (e) personal observations by the practitioner during an examination, or as the result of information received from the patientand which is based on acceptable medical grounds
A description of the illness or disorder informed consent of the patient the exact period of recommended sick leave; the date of issuing of the certificate of illness
a clear indication of the identity of the practitioner who issued the certificate which shall be personally and originally signed by him or her next to his or her initials and surname in printed or block letters . the medical practitioner is required to print his name and initials on the medical certificate in addition to his usual signature.
An examination by a nurse or other person who is not qualified to carry out examination and diagnosis is not acceptable. This means that any certificate bearing DOCTORS signature and a rubber stamp is acceptable
Confidentiality and the doctor-patient relationship 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. A certificate certifying illness may be issued when a patient’s state of health necessitates time away from the work-place. This may be because the employee cannot work or should not work.
Certification of illness for purposes of sick leave • Disability certificates is to workers compensation schemes, life insurance claims, accident compensation, superannuation, or other legislative schemes that have their own regulatory mechanisms.
The Responsibilities of Medical Practitioners Medical certificates are legal documents. Medical practitioners who deliberately issue a false, misleading or inaccurate certificate could face disciplinary action under the relevant Medical Practitioners Act (or its equivalent). Medical practitioners may also expose themselves to civil or criminal legal action.
Medical practitioners should not reveal confidential patient information.
While writing certificates minimizing the use of medical terms for easy comprehension Disclose only information that is accurate and based upon clinical observation, with patient comment clearly distinguished from clinical observation Clearly identify the examination date and the time period of treatment
Misleading or untrue information, either deliberately or negligently, is professionally unacceptable and may be referred to the appropriate agency. A doctor’s obligations are to his or her patient, and to the law.
Fitness certificates To return from a leave To Getting a job In factory In government service Overseas employment Employment in ship, air, space, police, military service etc. Fitness to torture- it is ethical malpractice how much person withstand torture
