Medical certificates and reports
July 2004
Information that should be provided
Medical statements should record the advice given to the patient along with other factual information including an accurate diagnosis except on the occasions when a doctor feels that it could be prejudicial to their patient’s wellbeing if the true diagnosis were given.
The ‘remarks’ sections on medical statements allow for additional comments about the disabling effects of the diagnosed condition, its treatment and prognosis. In cases where you consider that a patient would benefit from the help or advice of a Disability Employment Adviser (DEA) this opinion should also be included in the ‘remarks’ section.
Medical reports should indicate clearly the information required. Generally GPs should not speculate but should provide only factual information and should not certify something they are unable to verify.
GPs should be aware of the following guidance from the GMC’s ‘Good Medical Practice’.
Writing reports, giving evidence and signing documents
‘You must be honest and trustworthy when writing reports, completing or signing forms, or providing evidence in litigation or other formal inquiries. This means that you must take reasonable steps to verify any statement before you sign a document. You must not write or sign documents which are false or misleading because they omit relevant information. If you have agreed to prepare a report, complete or sign a document or provide evidence, you must do so without unreasonable delay.’