![]() ![]() This discussion should be documented in the medical record. If your report, based on the facts in the record, does not align with the patient’s expectations, explain your professional obligation to be factual and objective. In such cases, you may choose to write, “the patient reports that…”, and clarify that you did not assess them in real time. Occasionally, patients may ask for a letter about their state of health at a time when you did not personally assess them and may ask you to make statements that you cannot corroborate. Before you write your letter or complete a form, review the medical record and base your report on that information. ![]() Your report should be based on facts and be sound. If you are uncertain as to what the patient, SDM or executor/trustee has authorized, contact them and document your discussion in the medical record. Often, requests for reports or forms are received directly from insurance companies. Only content authorized by the patient, SDM or executor/trustee of the patient’s estate should be released. If you feel you cannot make the deadline, notify the requester at your earliest opportunity. the time period the report should cover. ![]() If the patient has died, consent should be obtained from the executor or trustee of the estate, after confirming their authority to act. ![]() If consent is obtained from a SDM, it is prudent to keep a copy of the legal document confirming the SDM’s authority to act on behalf of the patient in the medical record. Document that a note was provided and keep a copy of it in the medical record.įor more complex matters, or when the report or letter is to be sent directly to a third party, obtain express written consent from the patient before sending the report or letter. For simple matters and in cases where the letter will be provided directly to the patient while in the office, verbal consent is sufficient. Requests for a letter, form, or report can come from many different sources including the patient or a substitute decision-maker (SDM), the legal guardian of a child or an incapable adult, or from a third party such as a lawyer, insurance company, or government agency. Discuss with the patient that you may have to note the restrictions in your response. If the patient has placed restrictions on what they have authorized you to cover, indicate areas where restricted information is relevant to your response and/or results in an incomplete response. The answers you provide should be supported by the medical record but should contain only information the patient authorized to be released. If you are uncertain, are unable to answer a question or if it is outside your area of expertise, it is appropriate to indicate, “I don’t know”. Provide only factual information within your expertise, without bias or conflict of interest.ĭo not feel bound by check boxes that force you to a “yes” or “no” judgment. Don’t speculate on what lawyers, employers or others need. Respond only to the specific questions asked. Opinions are typically provided as part of independent medical examinations or in expert reports. The aim of a treating physician’s report is to provide facts, not opinions. Your reports should aim to be FAST: Factual, Authorized, Solid and Timely. Your College may consider the provision of untruthful information, the provision of information beyond the scope of the patient’s consent, or the inappropriate delay in producing medical certificates or reports to be professional misconduct. If you provide misinformation, or erroneous or unfounded opinions, employers and insurers who have relied on such representations may commence a legal action for damages against you or complain to your College. Physicians should be aware of the standards or guidelines of their medical regulatory authority (College) concerning the completion of medical reports. It is important to remember that patients, employers and insurers will be relying on the objective information you provide to make decisions for the patient that can include benefits, adjusted workplace environments, sick leave, etc. Requests for medico-legal reports (as when a patient’s lawyer requests a summary of their condition) are typically made in writing and usually state the purpose of the report. Requests for a treating physician letter or report are often made in person (as when a patient being examined asks for a “sick note” or for completion of an insurance company form). Good practice guidance Expand all Purpose of the report ![]()
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