'Sick Note 2'
Doctor Information
James Mcvittie
42 years old
Past Medical History: Nill known
Drug History: Takes no routine medication
Last entry:
Health check for over 40’s done in 2014, Qrisk was 9%, BP 125/85, non smoker, drinks 10-15 pints per week, mainly on a weekends. Not keen to make any changes today, but has been made aware re alcohol intake.
42 years old
Past Medical History: Nill known
Drug History: Takes no routine medication
Last entry:
Health check for over 40’s done in 2014, Qrisk was 9%, BP 125/85, non smoker, drinks 10-15 pints per week, mainly on a weekends. Not keen to make any changes today, but has been made aware re alcohol intake.
Patient Information
James McVittie, age 42
Opening Line: I need a sick note Doc
Setting the scene: you are a local ‘tough guy’ that always gets his way. No one says no to you. You have arranged an urgent appointment with the GP today because you need a sick note for two weeks ago when you missed your court hearing.
History if asked: Around 3 months ago you were out drinking with your mates, when someone needed a lift home. You felt it was only down the road, and you know that you weren’t drunk when you were driving. Unfortunately during the drive home, you failed to notice the police driving in their unmarked car behind you. They breathalysed you to find you were several times over the limit, and they proceeded to charge you with Driving under the influence. Your hearing was two weeks ago, but unfortunately you couldn’t make it as you had diarrhoea. The judge doesn't believe you, so your lawyer has asked you to make an appointment with your GP to get a sick note for that date. You didn’t see anyone as you are aware that doctors are under pressure, and didn't feel it warranted “wasting their time”.
If questioned you will reveal that your diarrhoea was self limiting, and had no red flag symptoms. It was associated with stomach cramps and lasted for 48 hours. You had no associated vomiting, but you felt nauseous. You feel perfectly fine now.
Your 'friend' has had a sick note from his Doctor under similar circumstances, after he had an operation, and the consultant didn't give him one at the time, so he had to go back to his GP later for one. Consequently you 'know' that you can get one.
Past Medical History: Nill
Medication History: Nill, NKDA (no known drug allergy)
Social: You drink around 10-15 pints per week, mainly on a friday - sunday night. You work as a Builder for a local firm. You are not interested in cutting down your alcohol, and don’t appreciate any advice from Doctors regarding this.
Ideas: You want a sick note
Concerns: Your solicitor has informed you that if you don't have a sick note that the penalty may be much harsher.
Expectations: Sick note, you’re not leaving without one.
How to respond: You will initially be calm and complementing to the doctor but only as long as they seem to be on your side, if they start getting difficult then so will you. You will get angry and swear, and unless you get the sick note you will storm out of the consultation. A Letter simply repeating what you've told the Doctor will not suffice.
If the Doctor states they are uncertain if they are allowed to write such a note / letter and they need to check with a colleague, you are more than happy to wait in the room whilst they go and do this. If they refuse to do it now, you will get cross saying, that your time is precious and you don’t want to waste it coming back later, and you need the letter / sick note now to hand in to your solicitor today, as you’re heading down there later.
The best outcome for you is if you get your sick note, you will then leave happy.
Opening Line: I need a sick note Doc
Setting the scene: you are a local ‘tough guy’ that always gets his way. No one says no to you. You have arranged an urgent appointment with the GP today because you need a sick note for two weeks ago when you missed your court hearing.
History if asked: Around 3 months ago you were out drinking with your mates, when someone needed a lift home. You felt it was only down the road, and you know that you weren’t drunk when you were driving. Unfortunately during the drive home, you failed to notice the police driving in their unmarked car behind you. They breathalysed you to find you were several times over the limit, and they proceeded to charge you with Driving under the influence. Your hearing was two weeks ago, but unfortunately you couldn’t make it as you had diarrhoea. The judge doesn't believe you, so your lawyer has asked you to make an appointment with your GP to get a sick note for that date. You didn’t see anyone as you are aware that doctors are under pressure, and didn't feel it warranted “wasting their time”.
If questioned you will reveal that your diarrhoea was self limiting, and had no red flag symptoms. It was associated with stomach cramps and lasted for 48 hours. You had no associated vomiting, but you felt nauseous. You feel perfectly fine now.
Your 'friend' has had a sick note from his Doctor under similar circumstances, after he had an operation, and the consultant didn't give him one at the time, so he had to go back to his GP later for one. Consequently you 'know' that you can get one.
Past Medical History: Nill
Medication History: Nill, NKDA (no known drug allergy)
Social: You drink around 10-15 pints per week, mainly on a friday - sunday night. You work as a Builder for a local firm. You are not interested in cutting down your alcohol, and don’t appreciate any advice from Doctors regarding this.
Ideas: You want a sick note
Concerns: Your solicitor has informed you that if you don't have a sick note that the penalty may be much harsher.
Expectations: Sick note, you’re not leaving without one.
How to respond: You will initially be calm and complementing to the doctor but only as long as they seem to be on your side, if they start getting difficult then so will you. You will get angry and swear, and unless you get the sick note you will storm out of the consultation. A Letter simply repeating what you've told the Doctor will not suffice.
If the Doctor states they are uncertain if they are allowed to write such a note / letter and they need to check with a colleague, you are more than happy to wait in the room whilst they go and do this. If they refuse to do it now, you will get cross saying, that your time is precious and you don’t want to waste it coming back later, and you need the letter / sick note now to hand in to your solicitor today, as you’re heading down there later.
The best outcome for you is if you get your sick note, you will then leave happy.
Examination Findings
Examination
Not strictly needed in this case: but if asked:
Observations all normal,
Abdomen soft, non tender.
Nothing abnormal found on examination.
Not strictly needed in this case: but if asked:
Observations all normal,
Abdomen soft, non tender.
Nothing abnormal found on examination.
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination and investigation Enquires about the illness, both past and present symptoms. Asks about complaint and explores patients understanding of the 'sick note' Explores patients' concern regarding the situation, and what might happen if he didn't get the 'sick note'. Enquires about alcohol / drinking habits. |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Doesn't ask about the alleged illness Fails to ask about the patients understanding of a sick note Fails to enquire about his alcohol / drinking habits. |
Clinical Management Skills
|
POSITIVE INDICATORS
Develops a management plan that is appropriate and in line with current best practice - which involves NOT issuing a sick note. Offers to help in other ways - such as writing a letter briefly outlining what the patient has told you today Offers advice re alcohol, even if the patient choses not to engage today Offers follow up should the patient want it. |
NEGATIVE INDICATORS
Colludes with the patient, and gives the patient a sick note. Does not offer any alternatives for the patient - such as a letter. Doesn't discuss or attempt to intervene re alcohol intake. Doesn't offer any follow up. |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan, without colluding. Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation - Is empathetic with why he wants the sick note. Is not judgemental towards patient's situation |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE An element of Dr-centered approach is required here, as you can not give a sick note, but this doesn't mean that you can't explore the patient's believes / wishes. Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation appears judgemental towards patient's situation |
Management
Management:
This is a difficult case, and one that we come across from time to time in General Practice. Some patients do feel a sense of entitlement, and feel that the GP would support them regardless of their demands. Some patients often feel that this support should also be given free even if its outside the scope of NHS work.
In this particular case you have to be mindful of the rules regarding ‘sick notes’ or now as they are commonly termed ‘fit notes’ or their official title from the department of works and pensions: “Statement of fitness for work”.
Here is an extract from GP Notebook about the fit note with the relevant detail highlighted in bold.
This is a difficult case, and one that we come across from time to time in General Practice. Some patients do feel a sense of entitlement, and feel that the GP would support them regardless of their demands. Some patients often feel that this support should also be given free even if its outside the scope of NHS work.
In this particular case you have to be mindful of the rules regarding ‘sick notes’ or now as they are commonly termed ‘fit notes’ or their official title from the department of works and pensions: “Statement of fitness for work”.
Here is an extract from GP Notebook about the fit note with the relevant detail highlighted in bold.
General points:
NHS General Practitioners are required to issue, free of charge, a Statement of Fitness for Work to patients for whom they provide clinical care
other doctors are also required to issue Statements where appropriate to patients for whom they provide clinical care
you do not need to issue a Statement to a patient until they have been off work for more than 7 calendar days
the Statement may be issued:
on the day that you assessed your patient;
on a date after you assessed your patient if you consider that it would have been reasonable to issue a Statement on the day of the assessment; or after consideration of a written report from another doctor or registered health care professional
You can also find here a link to a helpful article produced by the Department of Work and Pensions, that has a helpful FAQ section within, specifically written for health professionals.
Below is an extract from this article which is relevant to the above case.
Below is an extract from this article which is relevant to the above case.
When can I backdate a Statement of Fitness for Work?
A Statement of Fitness for Work (Med 3) can only be issued for a backdated period when it is based on a previous assessment.
An assessment is defined as the date you either had a face-to-face consultation, a telephone consultation or considered a report from another doctor or registered healthcare professional. You can issue a Statement on or after this date, but not before.
We recognise that there are some situations where your patient may ask for medical evidence to cover a backdated period for which there has not been a previous assessment – for example, if your patient has not been appropriately issued with a Med 3 on discharge from hospital or at a previous consultation with another GP.
In these situations, you cannot issue a Med 3 for the back dated period. However, in order to be helpful to your patient you may wish to, either in the comments box of the Statement or in a separate letter, provide advice that the patient was not fit for work for an earlier period. You should ensure you have the appropriate information and evidence to justify this advice – generally this will be via a report or patient record. Employers and DWP can accept this advice as strong evidence of fitness for work for social security and Statutory Sick Pay purposes.
