A client asked:
As far as I am aware, if you are booked off work, your doctor does not have to stipulate the reason you were off work. He only has to say you were incapacitated due to medical illness, is this correct?
Rule 15(1) of the Ethical and Professional Rules of the Medical and Dental Professions Board of the Health Professions Council of South Africa provides a yardstick as to what medical certificates should stipulate.
Rule 15(1) A practitioner shall only grant a certificate of illness if such certificate contains the following information, namely:
(a) the name, address and qualification of the practitioner;
(b) the name of the patient;
(c) the employment number of the patient (if applicable);
(d) the date and time of the examination;
(e) whether the certificate is being issued as a result of personal observations by the practitioner during an examination, or as the result of information received from the patient and which is based on acceptable medical grounds;
(f) a description of the illness, disorder or malady in layman’s terminology, with the informed consent of the patient:, provided that if the patient is not prepared to give such consent, the medical practitioner or dentist shall merely specify that, in his or her opinion based on an examination of the patient, the patient is unfit to work;
(g) whether the patient is totally indisposed for duty or whether the patient is able to perform less strenuous duties in the work situation;
(h) the exact period of recommended a sick leave;
(i) the date of issuing of the certificate of illness; and
(j) a clear indication of the identity of the practitioner who issued the certificate which shall be personally and originally signed by him or her next to his or her initials and surname in printed or block letters .
(2) If preprinted stationery is used, a practitioner shall delete words which are irrelevant.
(3) a practitioner shall issue a brief factual report to a patient where such a patient requires information concerning himself or herself.
From the above, it is clear – to answer client’s question – that the medical certificate must describe the illness in layman’s terms with the informed consent of the employee in terms of rule (f). This may not always be stated, particularly where the nature of the illness, if disclosed, may embarrass the patient.
If the employee goes to the doctor after s/he was ill, the doctor will describe the illness as a result of information received from the patient. The doctor will normally reflect that “I was informed that the patient, etc.” Unless the doctor can confirm that the employee was, in fact, ill as advised you do not have to accept this as genuine illness. The doctor is only telling you that the patient sayshe was ill. You would therefore be perfectly justified in informing the employee that the time taken off will be regarded as unpaid leave and that in future he should visit the doctor when he falls illand not after he has recovered from the alleged illness. Obviously, this could not apply where the employee was bedridden and unable to see the doctor when s/he fell ill.
Unless your leave policy stipulates otherwise, on those occasions where an employee takes only one day off sick s/he is not required to produce a medical certificate. Those days remain classified as sick leave days and are deductible from the employee’s sick leave entitlement.