Certificates Flashcards
Information regard Forms/Certificates
Latest HPCSA consideration is that traditional healers, pharmacists, nursing personnel and others may treat and even hand out sick certificates, even for
“unnatural causes” (weird) for illness. This will cause problems for employers to decide which certificates to accept as legal and reliable.
Dr’s authority lies therein that they may recommend sick leave. BUT employers may decide to refuse to accept certificates. They may even request a 2nd opinion. Or threat with legal action.
No general rule that any employer is entitled to know the health status of his/her employees. Drs are bound to maintain confidentiality.
Drs often in conflict: who to serve? Pt interest or employers interest?
Certificates etc are legal documents – To be: quality, accurate, honest, confidential, and Advised: legible, on drs letterhead, understandable, factual, by own observations
Act on basic conditions of service often complicates matters for the dr:
-Rights of employees re sick leave , maternity leave, family responsibility, right to withhold diagnosis –
- may lead to suspicion if you withhold facts/information
- Employer does not have to accept such a certificate
- Equal rights act: no discrimination on sickness - labor law also protects in case of discrimination
- May 2001: rule that no diagnosis to be divulged without explicit consent
What are Notes
Notes are basically any note made of an identifiable person of a consultation, examination, procedure =
Handwritten, typed, referrals, lab results,
audiovis, research data, other forms, certificates, archive material
Notes are and remains the property of a Dr, and forms part of the functioning of the practice
If there are any alterations; Make a line through it, sign, motivate and add the Date
What are the Contents of Notes
S.O.A.P
S-Subject
O-Objective
A-Assessment
P-Plan
Access of Notes
Copies/Access: 16yrs+, And to 3rd party when consent was given. TOP-No Access
Without Consent: Only in legal actions, disciplinary hearings, statutory duty to report, in public interest
Act 2/2002,Section 63-If there is harm to the pt,No access
Ethical Rule: It is the doctors discretion to decide what and what not to tell.
Duration of keeping Notes
Kids: 6-8 Years
Obstetrical Notes: 25 years
What are Certificates
Certificates are legal documents which have legal implications and they must always be honest and factually correct by own observations
Define the term Honesty
Honesty can be defined as whether if you are able to defend your notes in a court.
If the information is False,Untruthful or Misleading Certificates is referred to as:
-Guilty of professional misconduct resulting in a hearing and even removal from the Register
Fraud-Criminal
Problems with Certificates
Dates: No dates/Wrong
Information: Incomplete/Not at all/Lost
Handwriting, Corrections or Alterations are not signed, Abbreviations, Confidentiality
Other Types of Certificates:
Child Abuse:
Index of suspicions, If you suspect you must report.
Types of Abuse: Physical, Sexual, Emotional, Neglect
Occupational Disease/Injury(on duty):
Employer and Dr Reports
No Fee
Births:
Registration Parents Responsibility
Hosp. notifies the local authority
Forms at SAO/Local authority/Inland Affairs
May not conceal a Birth-Misconduct
J88; Assualt, Rape:
Complete notes on J88,may keep you out of court
Post-Mortem:
Only if you did it
Reasons whys doctors engage in the practice of issuing questionable or patently false medical certificates
A misguided act of kindness to their regular patients
Some simply succumb to the pressure of self-assertive and demanding patients
Some do it for financial gain
- It is wrong, unethical and illegal to issue false medical certificates.
- The recipients of the certificate (employers etc.) must be educated to seek a second opinion, and to refer questionable documents to the HPCSA
Sick-Certificates
Most Common Certificate – Dr Must Issue Self
A Certificate Allows Pt To Be Absent From Work And Gets Paid During Absence
– Act On Basic Conditions Of Service :
*Employer Does’nt Have To Pay If Worker Was
Absent For More Than 2 Consecutive Days, Or On
2 Occasions Within 8 Weeks, And Did Not Supply Valid Certificate
- Employee Allowed 3 Days Family Leave To Care For Kids, Sickness, Births, Etc
- Act Does Not Demand A Diagnosis !
Labour Law : Employer May Investigate The Nature
And Seriousness Of The Incapacity And It May Lead To
Discharge !
Must Be Factually Correct !!! Don’t Pretend That You
Examined A Patient. Do Not “Back Date” !
Certificate Usually On Request Of Pt = Implied Consent To Make Known / Divulge Diagnosis
Pt Must Hand It To 3rd Party/Employer
Who May Sign: Dr. ; Nurse For 3-4 Days. (Natal 7 Days)
Do Not Supercede A Certificate From A Colleague =
Displace It
Certificates From Eg Homeopaths Acceptable On
Employers Discretion
Number Days Recommended Off Vs Diagnosis Stated Must Be Acceptable
Sign All Corrections
Use Understandable Terminology
Copies ? Fee For Certificate ?
Diagnosis: Hpcsa 5/2001: No Diagnosis If No Informed Consent From Pt
Sick While On Leave:
May Deduct Period Of Incapacity From Days Leave
Taken .
Certificate and Diagnosis of HIV/AIDS
Only divulge information if insurer can prove that consent signed by patient or in case of death, by close relative
If Not: Write Confidential in the relevant spaces
Death Certificate
If the doctor was involved he has to issue a certificate of cause of death-For statistical purposes
Only DHA issues the certificate
If the doctor was not involved,He was issue a certitficate on condition that he/she saw the body and verified the facts
Nursing staff may also complete the certificate
You must report if you suspect Unnatural Causes
StillBirth
If the baby died before 6 months,It is regarded as a Miscarriage.
If baby <24 weeks old and lived,You must register
If the baby did not live outside of the uterus, and age estimation > 24 weeks, must register with a cause of death
Certificate of Cause of Death
Part A:
The Dr certifies only the Natural/Unnatural Cause
It is a public document and the Drs name appears on the form.
Handed to family or person who removes the body to the mortuary
Part B:
Confidential Document
Certifies the real cause of death and may include HIV
Sealed in an envelope,attached to part A and goes with the body to undertaker who has to send both parts to dept. HA.
Home affairs needs both parts: A to verify the death, B for stats and in the event that the seal of Part B was broken, DHA has to report to the DoH
