Should you give your patient a medical clearance?

Physicians may be asked to provide certificates of medical fitness for their patients in response to many different scenarios. Examples include certification of fitness to participate in an activity, applications for insurance benefits, or to grant a “medical clearance” for a patient to undergo routine dental or elective cosmetic or other procedures. Requests for medical clearances can come from the patient, dentist, cosmetic practitioner or other healthcare providers.

Physicians have a legal obligation to complete medical certificates and clearances concerning their patients when requested. If you fail to complete them, in many provinces and territories this may be deemed professional misconduct.

There may be instances where it’s difficult to assess a patient’s risk of a proposed procedure and provide the desired medical clearance. If you believe you are not the appropriate health professional to complete a medical clearance, advise the patient (and the third party if applicable) that you are unable to fulfil the request and, if possible, recommend the professional who would be more appropriately qualified.

When issuing medical certificates or clearances, the same professional responsibilities and standard of care apply as when providing medical treatment in general. So, what does that mean in practice?

The information you provide in a medical certificate or clearance should be based on what you know about the patient and within the scope of your knowledge and expertise. This is important because a third party will likely rely on the information you provide. When the information is accurate and within your scope, this will not only advance safe care for the patient, but it will also mitigate your potential medico-legal risk.

With the best interest of your patient in mind, keep these points in mind when responding to a request for medical clearance:

• Obtain the patient’s express written consent to disclose relevant personal health information. It’s good practice to discuss with the patient the specific information you plan to disclose, especially if the information is of a sensitive nature.
• Be careful to disclose only the information that is relevant to the request and covered by the patient’s authorization.
• Review the patient’s medical record to ensure your statements in the medical clearance are made to your best knowledge and belief and based on current clinical information.
• If you need more information to accurately complete the certificate, you may need to conduct an examination or assessment of the patient.
• Refrain from offering an opinion that is outside your scope of knowledge or expertise. Provide factual information about a patient’s condition that can be used by the person receiving the information.
• Be transparent about the limitations, if any, of the information you provide. If you are using a form, consider skipping sections you cannot complete, or attach a letter instead of the form. Let the patient (and the third party if applicable) know why you cannot complete the entire form.

Additional reading

• Preparing treating physician reports and IME reports
• Providing access to independent medical examinations
• Fitness to participate: Reduce your risk when patients ask for a certificate of fitness
• Doctors’ certificates: Real or fake?

DISCLAIMER: This content is for general informational purposes and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. Your use of CMPA learning resources is subject to the foregoing as well as CMPA's Terms of Use.