Relatórios médicos - lidando com solicitações

Doctors are frequently requested to provide information about their patients. These requests come from a variety of sources - eg, employers, government agencies, and regulatory bodies. In the UK, GPs receive the most requests, as it is they who hold the most comprehensive records and are the most accessible.

Information may need to be provided in the form of a medical report, a certificate, a statement, or a letter.

Difficulties may arise due to potential conflicts of interest, unreasonable expectations about the information the doctor may hold, and misunderstandings about the GP contract leading to issues relating to payment. Classifying the medical reports may help to clarify these issues.

Tabela 1. Relatórios médicos na prática geral britânica

Some application forms (eg, FP92A and FW8) can now be completed online although many GPs prefer to continue to complete paper copies.¹ Some examples are no longer commonly requested or required. For example, although schools still commonly request letters or certificates when a child has been unwell and unable to attend an exam, this is not part of the national guidance by the Joint Council for Qualifications and has been specifically addressed by their predecessor, OFQUAL.²³

Classes de relatórios médicos

Relatórios jurídicos que promovem o cuidado ao paciente

These will include:

• Recommendations under the Mental Health Act. This does not require consent. It is now very unusual for a GP to be involved in these reports.

• Child protection reports. Some child protection reports do not legally require consent (for example, a section 47 request) but most do. Child protection reports should attract a fee, paid for by the local authority.

• Assessment of mental capacity. It should be remembered that capacity is situation specific. Whilst it is not uncommon for GPs to be asked to perform mental capacity assessments, caution should be employed, particularly for requests where there may be future family disagreements (for example, the capacity to write a will or determine a lasting power of attorney). For most patients, a private psychiatrist or a lawyer will be best placed to provide this assessment. If a GP agrees to perform such an assessment, this attracts a similar fee to that which a solicitor would charge for the same request.

Legal reports to advance the public good

Doctors have an obligation to act in the public good. Examples of doctors exercising their public health function in this way include medical reports in notification of infectious diseases and adverse drug reactions. Death certification and medical reports to coroners provide important epidemiological information.

O consentimento geralmente não é necessário quando os médicos são legalmente obrigados a fornecer relatórios médicos, mas é uma boa prática informar o paciente sempre que possível.

Doença como direito ou fator de justificativa

This is the largest and most controversial category. A satisfactory system has yet to be found which ensures that patients using illness as an excusing factor are able to obtain sickness benefit without making unreasonable claims on the public purse. A variety of forms cover various circumstances in which sickness benefit or incapacity benefit is claimed. See also the separate Sickness certification in primary care artigo.

With increasing concerns about the number of patients requesting fit notes for mental health conditions, and many GPs feeling unable to challenge these requests due to time constraints, overwhelming workload or patient antagonism,⁴ at the time of writing there are plans to create a new system for fit notes which do not involve GPs. Pilot areas are due to trial a new system.⁵ There are hopes that this will improve support for patients to get into work, although there concerns have been raised about governance structures, training for those involved and where clinical oversight will come from.⁶

Other situations in which a certificate is requested in this category include: jury service, attendance at court, probation, or community punishments. It is very important to recognise that these should almost never be provided by a GP.

• Jury service: Patients can request to be excused from jury service and, if they claim illness or disability, they may be asked to provide a letter of proof from their GP.⁷This is a legal document and, should the court disagrees, the GP can be held in contempt of court. Courts are able to provide reasonable adjustments, enabling most people to act on a jury. Any letter should only be provided on sight of the court request.

• Attendance at court: Patients who wish to avoid attendance at court (either as a witness or as a defendant) can only be excused by the court. Serious ill health or emergency hospital admissions would be considered as reasons to fail to attend; these can usually be provided by the relevant hospital but may occasionally be requested from a GP (for example, where a patient has reached the end of their life and a decision has been made not to admit them to hospital). Any letter from a GP is considered a legal document and there have been instances where the GP has been summoned to give evidence regarding the content of their letter and to justify the basis for their statement that the patient was unfit to attend court.⁸ If such a letter is provided, it attracts a private fee.

• Probation: Medical emergencies and bereavement are considered acceptable reasons to miss a probation meeting.⁹ A letter confirming these may be requested. This attracts a private fee. A Fit note can only be provided for missing work. Whilst a patient who has a Fit note for work, may choose to also provide this to their probation officer, a Fit note cannot be given specifically for missing a probation meeting.

• Community punishment: As with probation meetings, a letter can be requested in the case of medical emergencies or bereavement. A Fit note cannot be provided for this purpose and any letter attracts a private fee.

Certificates or medical reports may also be requested to enable patients to access benefits such as free prescriptions, free travel on public transport, preferential access to social housing and parking. There is a specific form for free prescriptions (the FP92a for specific qualifying conditions and the FW8 for pregnant women and women in the first year after delivery). Requests for free travel on public transport or for disabled parking should come from the relevant local authority and attract a private fee. Local authorities or housing associations state that they rarely request GP information in assisting with housing requests; if they do request specific information then this request should come directly from them and attracts a private fee.

Fitness for sports or to fly

Reports certifying that a patient is fit to take part in sport may involve hazardous activities, such as bungee-jumping, or more mundane sports, such as gym training. UK organisations are now actively discouraged from asking GPs to becoming involved in these, due to the fact that the GP is neither trained nor indemnified to do so.

There are significant risks associated with signing a patient "fit for" any activity; sudden death during exercise almost always occurs in patients who were previously asymptomatic.¹⁰

There can be pressure from patients to complete forms, particularly for activities being done overseas or for charity. (Charitable causes requesting "fit to" letters often include parachute jumps. It is worth recalling that the cost to the NHS of parachute jumps is almost 14 times the value of money raised for charity).¹¹ Nonetheless the risks associated with signing these forms mean that they should very rarely (if ever) be done. Should they be done, they attract a private fee.

Fitness to fly requests are often related to pregnant women. GPs are advised not to state that anyone is "fit to fly" but it may be appropriate to give information about the gestational stage of the pregnancy and whether there have been any complications to date. Fitness to fly requests about specific medical conditions will usually require an assessment from a doctor trained in aviation medicine.

Similarly, requests about fitness to dive require an assessment from a doctor qualified to perform specific diving medicals.

Aptidão para uma ocupação

This may include driving (heavy goods vehicles and passenger-carrying vehicles) and health professions, such as occupational therapy and physiotherapy. The common theme is that those unfit to practise may pose a physical or mental risk to the public.

Detailed guidance on relevant health factors is provided by the Driver and Vehicle Licensing Agency and taxi licensing authorities. See also the separate Aptidão para Dirigir article. Forms for HGV drivers and taxi drivers are provided by their regulator or the DVLA. GPs often carry out this work; the private fee is specified by the regulator or the DVLA.

Health professionals in this category should not request these letters from a GP who is not able to provide specific advice on fitness to work. An occupational health doctor should be requested to complete these forms.

Informações para avaliações atuariais

These are commonly known as insurance reports. Their principal function is to help insurers assess an individual's risk of disability or death and weight premiums accordingly (or refuse insurance altogether). The framework governing the reports is clear; doctors writing them are obliged to give clear and accurate information, even if this is to the disadvantage of the patient. Since patients may not know what information is to be divulged, consent is generally carefully worded. It usually includes an option for an independent medical assessment if a GP cannot, or will not, provide a medical report, and provision for patients to view the information in the report and withhold information that they do not want divulged. These forms attract a private fee and most GPs will charge more than the BMA recommended fees.¹²

A common format for General Practitioner Report (GPR) has been agreed and computer-generated reports (eGPR) are accepted by insurers. Many GP software programs now have the facility to generate reports from within their systems, merging all relevant patient data. It is, however, still necessary for the GP to check that the data is complete and accurate before submitting the medical report.¹²

Relatórios não médicos

Confirming the identity of a patient is an example. These may come from pension providers overseas. This work is optional and attracts a private fee.

Problemas éticos

Consentimento

If the patient requests the medical report, consent may be implied or signed consent may be given. Signed consent does not always mean informed consent, and consent may be the only way to obtain insurance or benefits or take part in some activity. The right to see a medical report prior to submission is therefore important but legislation does not cover all reports. There may be a tension between the interests of the patient, the requirements of a third party and the obligations of a doctor to provide accurate information.

Orientação do Conselho Médico Geral

The General Medical Council (GMC) guidance, Confidencialidade: divulgação de informações para fins de seguro, emprego e similares (2017), states:¹³

The first duty of a doctor registered with the GMC is to make the care of their patient their first concern. You must inform patients about disclosures for purposes they would not reasonably expect, or check that they have already received information about such disclosures. As a general rule, you should seek a patient's express consent before disclosing identifiable information for purposes other than the provision of their care.

Se você for solicitado a fornecer informações a terceiros, como o segurador ou empregador de um paciente, ou a um departamento governamental ou agência que avalia o direito de um requerente a benefícios, seja após um exame ou a partir de registros existentes, você deve:

• Certifique-se de que o paciente possui informações suficientes sobre o escopo, propósito e possíveis consequências do exame e da divulgação, bem como o fato de que informações relevantes não podem ser ocultadas ou retidas.

• Obtain or have seen written consent to the disclosure from the patient or a person properly authorised to act on the patient's behalf.

Divulgue apenas informações factuais que possa comprovar, apresentadas de forma imparcial, relevantes para a solicitação e ofereça ao seu paciente a oportunidade de ver ou receber uma cópia de qualquer relatório médico que você escreva sobre ele para fins de emprego ou seguro antes de enviá-lo, a menos que:

• Eles já indicaram que não desejam vê-lo.

• A divulgação provavelmente causaria danos graves ao paciente ou a qualquer outra pessoa.

• A divulgação provavelmente revelaria informações sobre outra pessoa que não consente.

Se um paciente recusar o consentimento, ou se não for viável obter o consentimento dele, as informações ainda podem ser divulgadas se forem exigidas por lei ou se puderem ser justificadas pelo interesse público.

Ao escrever um relatório médico, você deve:

• Faça o seu melhor para garantir que não seja falso ou enganoso; você deve tomar medidas razoáveis para verificar as informações no relatório e não deve omitir deliberadamente qualquer informação relevante.

• Preencha e envie o relatório sem atrasos indevidos.

• Restringir o relatório às áreas nas quais você possui experiência direta ou conhecimento relevante.

• Certifique-se de que qualquer opinião que você inclua seja equilibrada e esteja apto a declarar os fatos ou suposições em que ela se baseia.

Pagamento

Payment for a medical report should be requested and received before the report is provided. Usually payment is provided by the party who requests the medical report (the patient, an official organisation or a commercial company). Fees are sometimes negotiated between the medical profession and the relevant authority. Some reports are part of the GP's NHS contract but most are not. It is advisable to have an advertised list of fees for the most common reports, so that it is made clear to patients that they will have to pay and how much the medical report will cost.

Doctors are occasionally requested to provide reports for no payment, such as charitable organisations, students seeking evidence of extenuating circumstances for an academic authority or patients requesting support for housing need. As in many other areas of clinical practice, this will require the doctor to make an individual judgement based on the merit of each request; as a rule these reports should not be provided by GPs but, if they are, there are few grounds for doing so for free.

Apresentação de informações

It is advisable to present the information in as factual a form as possible. Try to avoid making judgements or voicing opinions which are beyond your expertise. If you do not have the knowledge to answer a question (eg, whether the patient is fit for a job with which you are unfamiliar), say so. Most GPs, for example, will not have the expertise of a trained occupational health doctor - the professional the requesting body may need to involve (often at increased cost) if they cannot obtain an opinion otherwise. It is also important to recognise that some forms, for example those from the DVLA, often request information in a binary way with a YES/NO tick box. It is very reasonable for the GP to decline to answer in this way and to write a more accurate answer instead.

Remember also that medical records are not inviolate. They may be inaccurate, incomplete (for example, mislaid hospital reports, visits to alternative practitioners or NHS walk-in centres) or simply not fit for purpose (for example, functional information which GPs may not record). They may be valid from a clinical point of view but not from a legal point of view (for example, accounts of symptoms which had not been personally witnessed by the report writer would be considered hearsay in a court of law). All these points should be taken into account when writing a report.

Conclusão

Relatórios baseados nas informações dos médicos podem ser úteis e válidos. No entanto, organizações ou indivíduos às vezes solicitam relatórios médicos com base em suposições de que os médicos possuem mais informações do que realmente têm, para confirmar o que os pacientes já lhes disseram, ou na crença equivocada de que, ao fazer isso, podem transferir a responsabilidade pelo resultado do relatório para o profissional de saúde. Deve-se lembrar que os médicos não são obrigados a fornecer relatórios fora de suas responsabilidades legais e contratuais. Concentre-se nos fatos, e não nas opiniões. Não tenha medo de admitir que não possui o conhecimento necessário para responder a uma pergunta ou de sugerir que uma pessoa com maior expertise possa estar melhor qualificada para escrever o relatório médico, se for o caso.

Antes de escrever um relatório médico, pode ser útil considerar as seguintes perguntas:

• Em que categoria o relatório se enquadra?

• O paciente deu consentimento livre e informado?

• Quem se beneficiará do relatório?

• Quais são as consequências de entregar o relatório em vez de não entregá-lo?

• Quão válido é o conteúdo em que o relatório se baseia?

• Deve ser cobrada uma taxa e, em caso afirmativo, quem deve pagar e qual deve ser o valor cobrado?

• Está sendo solicitada uma opinião ou julgamento em vez de informações factuais e, se for o caso, você se sente confortável em cumprir os requisitos?