Warning to keep your notes shipshape

2 minute read

A tribunal has imposed conditions on a GP for writing medical certificates without recording sufficient details in his notes.

A doctor in small-town Victoria will now have to submit to quarterly audits of his practice after being pulled up for poor record-keeping in relation to medical certificates.

The Medical Board of Australia recently referred Dr Timothy Fitzpatrick to the Victorian Civil and Administrative Tribunal for writing potentially inappropriate medical certificates for six patients over three years.

But it wasn’t the GP’s clinical care that was at fault.

“The board did not suggest that Dr Fitzpatrick was dishonest, nor that the patients did not have reasons for their absences from work on the days or periods of time referred to in the certificates,” it wrote.

“There was no evidence to the tribunal that the medical certificates he had issued were false.”

Instead, he was referred to VCAT over concerns that the medical certificates he had written did not comply with the Medical Board of Australia’s Code of Conduct or the AMA guidelines on medical certificates.

“What went wrong here, in essence, is that Dr Fitzpatrick took some unacceptable shortcuts, skipping the steps (including good record-keeping) that are required before a doctor issues a medical certificate to a patient,” the VCAT decision read.

Of particular concern, the decision noted, was an instance where the GP had issued a certificate for a period six months into the future without making arrangements for regular review of the patient.

The tribunal heard that the patient was well known to Dr Fitzpatrick and that he had considered their personal history of stress and medication for depression and anxiety when he was writing the certificate.

“We accept that Dr Fitzpatrick, who is a general practitioner of good standing in his community, saw himself as helping out or advocating for the patients, particularly those who were struggling to manage highly stressful workplace issues,” the tribunal said.

“He knew them well, took them at their word, and did what he thought would help.

“But a doctor does his or her patients no favours if they issue medical certificates that ‘don’t pass muster’.”

The decision goes on to note that Dr Fitzpatrick has already made substantial changes to his practice and completed targeted one-on-one education.

Nonetheless, he was reprimanded and will have to submit his records to be audited four times per year for the next two years.

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