Fit note GP guidance for urgent forms and letters

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

Scenario 1

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.

Scenario 2

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.

Charlotte Hudson

Writer and editor at MPS. MPS’s educational risk management workshops, ‘Mastering Professional Interactions’ and ‘Medical Records for GPs’ provide further information on the risks to patients and doctors when patient care passes between doctors, and on good record-keeping. They are free as a benefit of membership to MPS members too.

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4 Responses

  1. Anonymous
    I would argue that in scenario 1, he is only unfit for heavy lifting and, therefore, a fit note should state such. Many postman to a wheely trolley or deliver by small van. I do not believe it is our job to decide if he is fit for his usual route - his manager could make some workplace adaptations.
  2. Does anyone else have experience of "my boss does not accept your note (patient given a Med3 stating clearly certain duties to be avoided and/or adjustments to work or duties) and says you must sign me off sick", and what to do about it?
    • Kim
      I always say they are the rules - the onus is on the employer to accept the fit note recommendations or not - if not then they can declare the employee unfit for work. I would not change the note on that basis. I have also printed off the guidance in the past - look on Gov website - and given it to the patient with the fit note.
  3. Tell the patient to see the occupational health Dr or Nurse if there is a dispute on what he can and can't do, they are the experts and will have a better understanding of what his job involves

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