Medical Certificates
In order for Worksafe agents to make an accurate assessment of an injured worker's recovery and compensation requirements, it is important that they have access to a timely and accurate assessment of the worker's medical condition. The preferred source of this information is the medical certificate.
Types of medical certificate
The term "medical certificate" is often used to describe a number of documents. As such, the certificate may be used as:
- A medical certificate
The first certificate issued, from which a diagnosis on the liability, injury severity and potential for ongoing incapacity is established. The certificate is lodged together with a new claim and can only be signed by a medical practitioner. The medical certificate can only be issued for 14 days or less off work, unless there are special reasons (e.g. where the worker has a severe injury or disease) which must be stated in the comments section of the certificate. - A certificate of incapacity
This is issued subsequent to the initial medical certificate. It may be signed by a medical practitioner, physiotherapist, chiropractor or osteopath. Because of the nature of this certificate it is often referred to as an "ongoing certificate'. - An attendance certificate
Issued when the patient is back at work and the employer requires proof of the worker's attendance at a medical examination or treatment. It is only necessary to sign the certificate, complete the patient's name, the date of examination and your name and address.
Nature of injury
The Worksafe agent makes a judgement on the type of injury classification based on the information entered in the 'Diagnosis and description of injury/disease' section of the form. Adequate information must be included in this section so the agent can establish liability and determine whether there will be any ongoing incapacity relating to the injury.
When the information is inadequate or where the explanation cannot be determined, the Worksafe agent is required to return the certificate. Descriptions such as "see previous certificate", "sore", "hurt" and "pain" are inadequate, as are illegible information and unknown abbreviations. Where this occurs, more information may be required to allocate a nature of injury code, determine liability or potential ongoing incapacity.
Further details on the allocation of nature of injury codes is incorporated in the VCode system.
When the nature of the injury is described so it adequately explains the injury or disease, the Worksafe agent can easily classify the injury. Immediate management of the worker's case can then begin.
Bodily location
Certificates must also specify the bodily location of the injury / disease. This is important information enabling the Worksafe agent to allocate the correct coding, determine liability and the potential for ongoing incapacity.
The location may be described with words such as back, shoulder or elbow or technical terms such as C3 or C4.
The bodily location does not need to be specified in cases where it can be determined easily by the nature of the disease or injury (e.g. myocardial infarction, stress/anxiety, emphysema).
Where relevant, the bodily location of the injury should be included in the Diagnosis section of the medical certificate.
Other important information on the certificate
The certificate also needs to include the date from which the worker will be fit for normal, modified or alternative duties, or unfit for any work. If any of these dates are prior to the examination date, you must provide details in the comments section.
- Normal duties
This means the worker is capable of returning to work and undertaking the same activities as before suffering the injury or disease. - Modified duties
This refers to any changes or restrictions that should be applied to a worker's pre-injury activities to allow them to return to work. - Alternative duties
These are duties different from those performed by the worker prior to the injury or disease.
Your role
The best outcome for your patient is to get them back to a normal, productive life as soon as possible. To help achieve this you can call the patient's employer to find out whether suitable employment is available for the worker, given their injury or illness. Based upon this advice and your diagnosis, you may be able to suggest one of the above return to work options taking into account some potential constraints:
- seated/standing
- no repetitive bending or lifting
- using right/left hand predominantly
- no contact with oils, solvents or other chemicals
- maximum weight for lifting or handling
- avoid repetitive use of affected body part
- frequent rotation of job tasks
- keep hand below waist/shoulder level
- keep wound dry/clean/covered
- avoid squatting/kneeling/ladders/steps.
By completing each medical certificate correctly you can play a part in the reduction of the incidence, severity and cost to the community of workplace injury and illness and facilitate better outcomes for injured workers.
