The medical certificate is nothing more than a testimony drawn up by a physician where he endorses the health condition of the requesting party (the patient or his legal representative).
It is important to bear in mind that the current state of the person must be reflected, corresponding to the moment of issuance of the document, and not one related to previous clinical studies .
Types of medical certificate
It can be said that there are two types of certificates, distinguished according to their regulatory obligation:
The first is the one imposed by law , marking the birth and death certificates within this group, which must inevitably be drawn up by the corresponding doctor.
The second group refers to the records written routinely within an office , often becoming the reason for consultation by which patients go to the health professional.
Characteristics of a medical record
Therefore, its writing should be carried out bearing in mind the following principles:
It is well known that doctors develop an unmistakable and at the same time unintelligible typeface; so this feature will be the first to be preserved.
Therefore, if it is handwritten, it is essential to improve the calligraphy; or failing that, consider printing as an alternative.
In turn, the use of abbreviations or codes should be avoided, in order to facilitate a clear and understandable reading by people outside the health field.
After the interrogation, complete physical examination and evaluation of complementary studies, the doctor reaches a conclusion about the patient’s state of health, understanding that the medical record must be faithful to what was determined as the reality of the clinical analysis .
The certificate is a statement of what was observed, examined and studied by the health professional, and should not desecrate with false assertions far from sanitary objectivity, which detract from the legality of the document and may represent an ethical-legal problem to future.
It must be consistent with what is stated in the format, the document must maintain a logical drafting order and be consistent with the projected state of health.
Likewise, it must describe the findings that converged in the diagnostic impression.
It is relevant to clarify the activity for which the applicant is considered competent , thus limiting the inappropriate use of medical records to prove functions that are not suitable for the patient.
Medical certification is a legitimate process and your writing must state this fact.
In this sense, it is advisable to use letterhead, noting the complete identification of the patient and the data corresponding to the preparation of the record, as well as the signature and stamp of the physician.
In order to “cover your back”, the medical statement should always be recorded in the medical record; in this way, if a judicial investigation were carried out, it would have the support of what was expressed in the certificate.
When is a medical certificate necessary?
This document may be required in various settings, both work and school or in daily life; then it is had that a medical certificate can:
Medical evidence to legitimize pathological processes
In which case its usefulness is to validate and support the reason for absence from a place where the patient had the commitment to be, whether for work, academic or other pertinent reasons.
Dra. Adriana G. Oropeza A.
Professional license: xxxxxxx.
After carrying out a deep anamnesis, detailed physical examination and paraclinical assessment, through this document I state that Miss María Araujo Pereira, 20 years old, CI No. xxxxxx, presents a picture of acute otitis media in evolution , which is why 72 hours of rest are indicated, in conjunction with medical treatment.
I sign this medical certificate at the request of the patient, for the purposes that she deems necessary.
Signature and stamp of the doctor.
Medical certificate to certify physical or mental capacity
This being a habitual requirement of occupational positions or of different entities, in order to guarantee the correct performance of the applicant.
In this situation, medical evidence may be necessary prior to carrying out any activity that requires somatic, psychic or cognitive abilities, as well as the preservation of certain senses, without which the physical integrity of both the person and the person could be endangered. third parties.
Such is the case of the certification necessary to obtain a driver’s license, or the handling of weapons.
Likewise, it may be essential to present this document before performing any physical work that requires skills and appropriate health conditions.
WHO MAY CONCERN
I, Dr. Pablo Méndez Peña, internist, professional license xxxxxx, having carried out the detailed clinical evaluation, have verified that Mr. Miguel Martínez, 39, CI xxxxxx.
He is in perfect health, without cardiorespiratory pathological findings, and with general preservation of all his senses, as well as his neurological sphere where he is oriented and with preserved coordination. Therefore, it does not present any impediment that limits it to the performance of its functions.
This medical report is issued at the request of the patient, for what he deems pertinent.
Signature and stamp of the doctor.