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Documentation for Medical Reviews or Referrals

Key Takeaways

  • Be Proactive: Always request your attendance certificate before leaving the receptionist at your specialist appointment.
  • Confidentiality Rights: Only your employer is provided with information that you are unfit for work or that you were attending a medical appointment; hence, you do not need to disclose to them your medical condition.
  • Link Through Your GP: Your GP can help translate the specialist's recommendations into "Fit-to-Work" plans with more specific duties.
  • Digital Convenience: Telehealth sessions are a great way to manage referral letters, review a specialist's report, and obtain work-related documents without leaving your seat.

Hello! I'm a GP, and I get it: the paperwork side of the healthcare industry can sometimes be more frustrating than the actual health issues. You might have completed the referral process, waited a few weeks for the specialist appointment, and finally attended the visit, only to discover you had forgotten to obtain a certificate for your employer.

Workplace documentation plays a vital role in balancing your health and securing your employment rights. Generally, you have the right to privacy and personal leave, provided you have the appropriate documentation, whether you are undergoing a simple check-up, a specialist review, or a diagnostic scan.

This article explains "who, what, and how" of obtaining medical documents for referrals and reviews, so that you can comply with your workplace's requirements without disclosing your private medical history.

Reasons Why Medical Documentation Is Essential for Specialist or Review Appointments

The Fair Work Act 2009 recognises personal leave as an employee's right. An employee may take personal leave if they are sick or injured, or need to care for an immediate family member. Moreover, the employer may require "evidence that would satisfy a reasonable person" confirming that the absence of work was for a legitimate reason.

What Should an Attendance Certificate Be?

A specialist review's documentation can look quite different from a typical sick leave certificate. The latter is a statement indicating that the employee is unfit for work due to illness. On the other hand, one purpose of a specialist review document may be to verify that a person has attended the appointment.

Let's say that you need to leave work at 2 pm to see a cardiologist or a physiotherapist. In this case, your employer will want to ensure you have genuinely been to the clinic.

  • HR Compliance: Employees can accurately log their leave time.
  • Entitlements: You do not lose your rights to payment for time off.
  • Duty of Care: This is the documentation of any work-related injury that the insurance company must be aware of.

Organising the necessary paperwork in advance reflects good manners and helps maintain a good relationship with your employer.

For further details on our role in administrative compliance, refer to our Quality Compliance standards.

What Details Should Be on a Review Certificate

A common question I get is: "Should my employer know which specialist I am seeing?"

I will give you the brief and simple answer that "No".

Medical Confidentiality

Your medical information is highly confidential. In most cases, the Medical Certificate or Certificate of Attendance need not include the diagnosis, the type of specialist consulted, or any details about a medical condition.

The Basic Elements of a Medical Certificate for a Referral/Review

Generally, certificates that doctors issue when a patient has a review or a referral appointment will have the following:

  • Patient's Name: To confirm the identity of the patient.
  • Appointment Date: The exact date (sometimes time) of the appointment.
  • Doctor's Name: The name and address of the doctor or clinic.
  • Attending Statement: A line that says, "This patient attended a medical consultation on [Date]."
  • Length (Optional): Indicates whether the patient was unfit for work for the duration of the appointment or for the entire day.

You don't have to disclose review results to anyone unless they concern your work safety, which is addressed later.

See our Privacy-Friendly Documentation area to learn how we handle your data.

Referral-Related Documents Issuance by Telehealth GP

Sometimes, a specialist or radiologist may forget to issue a certificate while still at the clinic. Further, if you have had a consultation with the specialist who cleared you for return to work and you want to discuss the "next steps" with your usual GP, then Telehealth is a good option.

Telehealth GP as a "Bridge" Between Specialist and Work

There are three ways a Telehealth GP can help consolidate your care.

  • We can review the specialist's letter together via video call if the consultant has advised your GPs on your behalf.
  • Because we can review your condition or the specialist's report together with you, that session is also a medical one. We can give you a certificate for this telehealth consultation.
  • We assure you that all letters and reports from your specialists are kept in a single folder and can serve as a complete record if you need insurance or new referrals in the future.

Book a Telehealth GP Consult if you need to see a specialist, or if you're new to discussing the report and managing your paperwork for your return to work.

When Specialist Input Requires More Detailed Fit-to-Work Notes

One particular circumstance requires more detailed documentation of your ability to work. That is when your work capacity will be substantially affected by the doctor's advice/work limitation.

Supposing you work as a warehouse picker and you are receiving treatment from an orthopaedic surgeon because of a back problem. Then the doctor might say.

It's a case where just providing an "Attendance Certificate" is not enough. You also have to obtain a Fit-to-Work Certificate (or Clearance Certificate) indicating the sort of duties you are allowed to carry out.

Giver's Role:

It is not unusual for specialists to be so focused on treating patients surgically/medically that they forget to write their own work plans. A GP can take a specialist's advice and turn it into a "Capacity to Work" letter that the employer easily understands.

  • Clear Restriction: We make a list of what that person can or cannot do (e.g., "No ladder climbing." "Seated duties only.")
  • Timeframes: We set the duration for applying these restrictions (e.g., "Review in 4 weeks").
  • Safety First: As a result, you are not obliged to perform any task that may harm you again.

Through this collaboration, your employer is fully informed about how to support your return to work. Read more about Clearance After Specialist Advice.

Telehealth for Review Paperwork

Medical reviews are not always held during office hours. Your MRI may have been delayed, or you had an evening consultation appointment.

You may need to return the next morning with the required documents. But then, your regular clinic will be closed. You can get help from after-hours telehealth.

  • You can speak with a doctor about the documents you need to support your absence from work, review your review results, or request an attendance certificate via after-hours telehealth.
  • Digital certificates are sent by email instantly, so you can forward them to your HR department before the workday starts, saving time.

We serve shift workers and busy executives who need after-hours medical documentation.

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