POLICY - Physician Certification of Work Absence or Accommodation Due to Illness or Injury and Completion of Third Party Forms
This document a policy of the College of Physicians and Surgeons of Saskatchewan and reflects the position of the College.
Practising medicine involves much more than preventing, diagnosing and treating illness. Caring about the patients' well-being are attributes of a physician.
Physicians regularly find themselves petitioned to certify time off work via the completion of "sick slips" or third party forms from a patient's employer or disability insurer. This task is, most often, arduous and consumes substantial amounts of time.
When places of employment request information related to their employee's illness, they are trusting that the physician will provide accurate, appropriate details concerning the employee's absence. It is expected that the medical profession will be objective in determining the contents of the Sick Slip.
Many times the doctor/patient relationship can be strained when the patient disagrees with the contents of a sick slip or disability form as completed by the physician.
It is imperative that a physician is convinced of the facts around the illness, and conscientiously determines the appropriate period of work absence due to disability or the degree and duration of work accommodation required.
Issuing a Sick Slip is a very important matter. Stakeholders rely on a physician's expertise in determining what is right or fair. The same parties work under the assumption that a treating physician has had specific training in determining disability and work accommodation. This assumption is, in most circumstances inaccurate. Therefore it becomes incumbent on the physician to ensure the contents of the note or form are objective and formulated based on accurate assessment of patient reported complaints, and careful physical examination.
The following is a list of suggestions which should provide a balanced, common-sense approach to issuing Sick Slips:
- Always assess the patient for true disability.
- When possible, recommend appropriate alternative level of employment or reasonable work accommodations, if not totally disabled.
- Carefully document the facts as presented to ensure reproducibility.
- When determining the duration of work absence it is important to take into account the perspectives of the patient and the employer. These perspectives should inform decision making but should not be the sole basis of decision making.
- Estimate an appropriate period of disability based on objective assessment of the injury and illness. "Normal" expected recovery periods should be used to predict return to work while allowing for patient specific factors as modifiers.
- If you perceive that a patient disagrees with your assessment, have a frank, honest discussion with the patient prior to releasing the Sick Slip.
- Never accept telephone or digital information regarding an illness for the purpose of issuing a Sick Slip.
- A signed consent for release of information must accompany the sick note on the medical record. Consent should specifically state if diagnosis is to be released.
- Sick slips should be based on physical examination during the period of illness or injury. In the event that a patient requests a slip validating an unverifiable illness or injury, the physician should not feel obliged to provide such a note. Any retroactive note provided should validate the patient's accurate reporting of an illness, rather than validating the illness itself.
Assessment of Capacity for Work and/or Accommodations Required
The purpose of the above is to verify an illness/injury to an employer or insuring agency and to provide relevant information to enable the patient/employee to return to work as soon as medically possible.
While "Sick Slips" are a brief certification of illness or injury, they often contain a certification of a brief absence from work for illness or injury. In the case of more severe illness or injury, a longer time off work is often required, and a graded return to work (6RW) or assessment of accommodations may also be required.
The Canadian Medical Association has identified four elements to the role of the treating physician in helping a patient return to work.1
Providing medically necessary services to the patient related to the injury or illness to achieve optimum health and functionality.
Providing objective, accurate and timely medical information for the consideration of eligibility of insurance benefits.
Providing objective, accurate and timely medical information as part of the timely return-to- work program.
Considering whether to serve as a Timely Return-to-Work Coordinator when requested by the employer/employee or other third party.
Employers and their insurers will be relying on the information provided to them and in so doing, they may incur financial liability for sick leave, or disability pay. Completion of more exhaustive documentation may be required in order to validate compensation to the ill or injured worker. The employer is also relying on the physician's opinion that the employee is fit to return to work. Misinformation, or erroneous opinions, could result in harm to those relying on this information.
Factors to consider when certifying major illness or injury and assessing capacity for work include:
Some illnesses/injuries may impair a person's capacity to do their regular work or alternative work. However, planning for return to work should begin at the first visit. A patient's limitations should be evaluated and emphasized to him/her. Work and other activities should be encouraged within the patient's evolving limitations.
It is the responsibility of the employer to manage the worker's return to modified or usual work duties with the benefit of objective professional input from physicians and/or other health care professionals. It is incumbent on the employer to provide the physician with clear documentation of the worker's duties in order to guide discussion as to capacity for work or accommodations required.
With respect to worker injury/illness incurred in the workplace, the procedures defined by the Workers' Compensation Board (WCB) apply.
The responsibility of the physician is to do an objective evaluation and to report the impact of an injury/illness and the limitations that the patient/worker's injury/illness places on their ability to perform certain functions. In circumstances where a physician does not have the formal training required to make such an assessment, recommendation of a formal physical or occupational therapy assessment may be indicated.
To the extent that it is possible, functional capacity and limitations should be assessed objectively. It is, however, recognized that in formulating any professional opinion regarding a patient's/worker's functional capacity or limitations, a physician may be substantially reliant upon information from the patient/worker regarding subjective elements related to their injury such as pain, anxiety or dizziness.
- It is prudent to avoid long-term prognostic opinions but rather to re-evaluate an injured worker's functional capacity at regular intervals. Many employers can align a modified job if they know an employee's capabilities and/or restrictions and will be counting on a physician's report to enable this process. An employer needs to know approximately when they can reasonably expect an employee to be able to return to their regular duties. This way they can properly manage and plan for the changes in their workplaces. They will generally be looking to the physician for an anticipated return to an employee's regular work date.
- Any release of information to an employer should be strictly on a "need to know" basis, limited to the worker's injury/illness and only after the patient has provided a signed consent for the release of such information. Consent must be specific as to the release of a diagnosis, as compared to release of information pertaining to accommodations or return to work dates.
- With respect to more extensive illness/injury that may involve early return to work with modified strategies, the following sequence of assessment and reporting is recommended:
(a) At the time the injured/ill patient attends a physician pertinent history and physical are performed. If information is to be passed on to an employer/insurer then informed consent must be obtained.
(b) An initial form or assessment note is completed and returned to the employer indicating the nature and extent of the condition and functional limitations.
(c) The employer discusses a modified work option that might allow the employee to return to work.
(d) The employer sends a summary of the modified work plan with the employee to the physician for review.
(e) The physician certifies the ability of the patient to undertake the proposed modified work plan and establishes and appropriate date for review.
(f) Following review, the patient/employee may increase the scope of work as the limitation of the medical condition allows
- Completion of forms, notes or letters certifying illness or injury are often time dependent. It is the responsibility of the physician to complete such documents in a reasonable time frame. In general, such documents should be completed within 30 (thirty) days of receiving the request. This guideline applies to, but is not limited to the following:
(a) Sick Slips
(b) Third party insurance forms solicited by the patient
(c) Third party disability forms solicited by the insurer with appropriate patient consent
(d) Third party return to work forms solicited by employers
(e) Third party progress notes required for ongoing assessment of benefits
(f) Responses, either favorable or not, to requests for medicolegal opinion
(g) Responses to requests for information from a third party engaged in the treatment of the patient
- Completion of forms is a non-insured service. As such, physicians should be clear with patients as to any cost incurred by the completion of the form. In general, a physician should adhere to the recommendations of the SMA with respect to fees for form completion. The physician should assess the patient's ability to pay for forms, and should not unduly penalize a patient who is legitimately unable to pay.
1 The Treating Physician's Role in Helping Patients Return to Work After an Illness or Injury http://policvbase.cma.ca/dbtw-wpd/Policvpdf/PD13-05.pdf
Approved by Council:
June 24, 2016
To be reviewed: