Dr Rachel Birch, MPS medicolegal adviser and sessional GP, presents two case scenarios highlighting fit note GP guidance on how to handle patient requests for fit notes and letters
You are doing a one-day locum. You see Mr H, a 32-year-old patient with a six-week history of low back pain. It is worse with movement but there is no radiation and there are no red flag symptoms. He tells you that he works as a postman but has not been to work for six weeks due to the pain.
Examination reveals slight tenderness across the lower lumbar muscles but no bony tenderness. He has full range of movement and straight leg raising, together with an neurological examination, are normal.
You diagnose mechanical back pain and advise on analgesia and exercises. You offer to refer him to physiotherapy. Mr H declines this and states he is “only here for a sick line”. He asks you for a backdated sick line, to cover his time off work. He says he has been to see Dr A twice about his back pain.
You look in his medical record. He was seen by Dr A six weeks ago with otitis media. He also attended four weeks ago, and although Cocodamol was prescribed, there is nothing documented in the consultation.
What should you do?
- Explain to the patient that you cannot backdate his fit note. There is no record of back pain in the medical record.
- Do not feel pressurised into providing a fit note. Although Cocodamol was issued four weeks ago, you cannot be certain that this was for back pain.
- Advise the patient to see Dr A when he is back from annual leave. This request is not urgent.
- Leave a message for Dr A, asking him to address this when he is back at work.
- You may wish to offer Mr H a fit note from today’s date onwards, if you clinically deem that he is unfit for work.
You should keep clear and contemporaneous notes, which will be important in demonstrating that you acted reasonably and appropriately should Mr H pursue a complaint.
Fit note guidance
The Department of Work and Pensions offers guidance on the completion of the Statement of Fitness to Work (Fit note).
Before completing a fit note, the patient should be assessed for fitness to work. This can be by face-to-face or telephone consultation. As part of the assessment, doctors may also consider reports from other doctors of healthcare professionals.
You are doing an afternoon locum session at short notice as Dr S is unwell. The receptionist sends you a message. Mrs T, a 52-year-old patient, has been asked to do jury service next week. She spoke with Dr S yesterday and he promised to do a letter of exemption. She came to collect the letter but it is not there. She is very angry and is apparently coming back in an hour for the letter.
You review the patient’s notes. There is no record of a conversation with Dr S. She was last seen eight weeks ago with rectal bleeding and at that stage was treated for presumed haemorrhoids.
You try to telephone Mrs T but her phone is switched off. She returns later and is very tearful when she discovers there is no letter. The receptionist phones you. Mrs T says that her symptoms are much worse and there is no way she can sit through jury duty.
What should you do?
- The patient’s main concern is to obtain a letter to exempt her from jury duty.
- You do not have enough information to provide a letter. You should therefore review Mrs T, in order to determine as to whether or not she is fit to undertake jury service.
- Mrs T has a history of rectal bleeding and stated that her symptoms are much worse. In her age group, this should be assessed further as it may be a red flag, signifying a possible cancer diagnosis.
- You should review the patient today and conduct an examination. She may need urgent referral for further investigation.
- Once you have addressed her clinical needs, you can also comment honestly on her fitness to do jury service.
- If you do agree to provide Mrs T with a letter confirming that she is unfit for jury service, then you should put yourself in a position to justify your opinion if called upon to do so by clearly documenting the rationale for your decision in the records.
General Medical Council guidance
You must be honest and trustworthy when completing documents or letters. You should take reasonable steps to ensure that any documents you write or sign are not false or misleading.