Medical Documentation – Let’s get it right!


Colin Finlay

“There is no better feeling than knowing what you do matters.” – Colin Finlay

An employee comes forward and tells their manager that they have a note from a medical professional…

In my experience this is how what should be a simple conversation often turns into an emotionally heightened state of confusion. Let me illustrate how this happens.

  • Medical professionals typically write a medical certificate that illustrates what solution they believe is in the best interest of their patient’s physical or mental health. For example: “Unable to work from [date] to [date].”
  • Employees often come forward with the impression that whatever the doctor has written must be adhered to, while at the same time and understandably so, prefer not to disclose details related to what was written on the paper supplied by the medical professional.
  • Managers at times are left in a state of ambiguity, uncertain of what to do with the information the medical professional has provided on the documentation, and at times with good reason question the validity of what was written.

Countless times I have seen this scenario unfold not because the employee is trying to manipulate a system that is designed to help people get back to work and not because a manager isn’t sure what to do with the information that was provided on the medical certificate. The reason for all the confusion is most often because the wrong information is being provided by medical professionals.

In today’s world very little privacy is left for people, but when it comes to medical information we can count our lucky stars that under most normal circumstances this information has legally been protected. In most circumstances a person is not required to disclose a medical diagnosis to anyone unless they decide they want to. The reality in the context of “accommodations in the workplace” is that people shouldn’t have to. Employers simply don’t need this information to assist someone in the workplace or through a return to work plan.

It’s also my experience that most medical professionals don’t seem to understand what information they can provide. So in light of not understanding what information they can share, they simply more often than not write down operational directions for employers explaining what the employer should do for the employee/patient. Unfortunately the reality is also that medical professionals don’t dictate the operational functionality of every business in existence, nor do they have the contextual understanding of every position to make such uninformed decisions.

Perhaps medical professionals focus so heavily on what not to write, they don’t get enough practice writing the information they can share?

I’m not sure what the root cause of this is, but I do know that this consistent lack of understanding between employees, employers and medical professionals is troublesome and causes increased levels of stress to everyone without need. It also robs time away from the medical professionals who could be helping someone else rather than re-writing a note that needs clarification because a patient is upset in their office. It’s frustrating for everyone.

In the interest of helping everyone understand how we can all help each other allow me to clarify some differences between a diagnosis, a restriction and a solution for the general purposes of medical documentation for employment purposes:

  • Diagnosis – This is the actual medical condition that the employee/patient has been found to be facing. Examples may include the following:
    • Broken leg
    • Depression
    • The flu
  • Restriction – This is a limitation related to the diagnosis that may prevent an employee/patient from functioning at full capacity both in and out of work. Examples may include:
    • Must keep leg elevated when seated. Unable to stand for periods greater than 20 minutes without sitting for 1 hour.
    • Must not work in isolation for more than 2 hours at any given time. Should be allowed 3 periods of at least 15 minutes of natural light within an 8 hour period.
    • Must have bed rest for extended periods through the day for the next 5 days.
  • Solution – This is an idea that should be discussed between the employer and employee to overcome the restrictions that have been put in place by a medical professional. It should take into account both the medical restrictions of the employee/patient and the operational requirements of the position(s) in the employer’s organization. Some solutions may include:
    • Unable to come to work or the employer could provide a leg rest for the employee when they are seated and ensure they do not stand for periods more than 20 minutes in length without being able to sit for 1 hour in between these periods.
    • Unable to come to work or the employer may situate an employee in an office space to ensure the employee/patient is not left in isolation. During the employee’s coffee and lunch breaks they should also make an effort to go outside in order to get periods of natural light that are needed.
    • Unable to come to work or … well sometimes it might just be best to not come to work.

So what should a medical professional include on the medical certificate? The answer is restrictions and only the restrictions.

A medical professional should not be sharing the diagnosis of their patient. This information is protected through legislation in most areas, but also, it just isn’t relevant information needed to work towards a plan to help a person stay or return to work.

Nor should a medical professional write what their opinion of what a potential solution might be. While they may have a good idea, they do not have the contextual understanding of the work environment, nor do they understand what possible accommodations may be available. It’s irresponsible to make such an uninformed decision and set the stage to contribute to higher levels of stress for everyone involved.

When employers and employees/patients understand what the restrictions are, this can lead to productive discussion to meet the needs of everyone. An employer may be able to assist someone continue with work and lessen the burden of time away without pay. An employee/patient may be able to remain in a social environment which has been shown in studies to enhance the healing process for most people. Meanwhile, medical professionals would have more time to assist people with more urgent needs than re-writing medical documentation until it is “deemed satisfactory to the employer.”

So next time you find yourself seeking the advice of a medical professional and asking for a medical certificate for your employer, remember to ask them to write down the specific restrictions related to the circumstances being faced.

This entry was posted in Employee Relations, Human Resources, Wellness. Bookmark the permalink.

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