Doctor’s notes

It is the OMA’s position that doctor's notes are not an appropriate use of primary care resources.

Professional obligations

If you do receive patient requests for notes, it is important to understand your obligations when faced with them.

CPSO third-party reports policy

For all doctor’s note requests, the guidance set out in the CPSO’s third-party medical reports policy applies. Key points from the policy include:

Treating physicians must:

  • Provide third-party reports (including notes) when requested. A third party is defined as any person or organization other than the physician and patient (e.g., insurer, government, employer, educational institution, lawyer, etc.)
  • Take steps to obtain and review all relevant clinical documentation
  • Obtain and document patient consent

The report (or note) must:

  • Contain only necessary and relevant information
  • Contain accurate information and state any limitations (whether due to availability of documentation or because it is beyond your expertise/experience)
  • State findings or opinions objectively and free from personal bias
  • Note the source of information (if not individually substantiated)
  • Use language and terminology appropriate for the audience

The report (or note) should:

  • Outline the basis for your professional opinion and the information or observations that you relied on to form your opinion

Using clinical judgment

You will need to use your clinical judgment to assess the patient’s condition and evaluate the risk posed by their circumstances.

Billing

Doctor's notes are not an insured service. Notes can be billed directly to the patient or to the third party (where they are the requestor). The 2024 Physician's Guide to Uninsured Services provides two suggestions to determine a fee:

1. A basic doctor’s note: $23.50

  • This includes a short note that serves the purpose of briefly confirming an exemption (wearing a mask; attending work/school) or clearance to return to work/school

2. A doctor’s note (or report), that requires a more detailed explanation about the patient’s diagnosis, current capabilities and/or ongoing management: There is no recommended fee for this service.

  • Members should determine a fee that is reasonable for the work involved and that considers each service independently. When the assessment is not medically necessary, an additional appropriate assessment fee may be charged to the patient/third party on top of the fees charged for completing third-party forms, reports and notes

Responding to requests for notes

Your role

Your role is to evaluate the patient and use your clinical judgement to determine if vaccination may present a medical risk to the individual. If there is a medical risk, state the time period that the risk is in effect. For information to help you determine when a medical exemption from COVID-19 vaccination may be warranted, refer to the Ministry of Health’s COVID-19 vaccine guidance and the OMA’s pathways to COVID-19 vaccination for patients with allergies.

If it is your opinion (based on the clinical evidence and information available to you) that the patient does not have a medical condition that would prevent or impede them from COVID-19 vaccination, it is your professional and legal obligation to withhold the exemption. Respectfully explain to the patient the reasons why a note cannot be provided for this purpose.

The CPSO Medical Records Documentation policy sets out core expectations for physicians related to the documentation of clinical encounters. In addition to documenting details of the clinical assessment, the OMA strongly encourages members to document conversations about vaccine exemptions. Documentation should include the decision of whether to provide a note, rationale, ensuring the criteria for any note provided completely meets the regulatory requirements, and a copy of the note if one is provided.

According to the Ministry of Health’s COVID-19 vaccine guidance, medical exemptions no longer need to be documented in a patient’s COVax record. When a third party, such as an employer, requests information about a patient’s health care status or needs, you are obligated to comply with CPSO guidance. You are not required to determine the outcome of the process (i.e. how the patient should be accommodated). You are not required to comment on any other grounds (e.g. religion).

Sample language for note

The CPSO states that any notes exempting individuals from receiving the COVID-19 vaccine need to clearly specify the reason for the exemption. Where applicable, add any detail necessary given the circumstances relevant to the situation.

The note should specify the time period of the exemption. The time period indicated should reflect the next expected reassessment of the condition, at which point the need for exemption can be re-evaluated. This could include a pending evaluation by an allergist/immunologist or another specialist to determine if and how the individual may safely receive the vaccine. The time period indicated should also reflect whether the medical exemption is pending developments in medical knowledge (for example, if the exemption could be removed when more becomes known about myocarditis/pericarditis).

You may use the following sample language for requests that need a note for an exemption from the COVID-19 vaccination:

I attest that based on my knowledge of the patient and the information available to me, __________________ [PATIENT NAME] has a medical condition that prevents them from receiving a COVID-19 vaccine.

This exemption is valid for the following time frame:

Check one of two options:

  • Indefinitely
  • Time limited, until the following date: __________________

Visit OntarioMD for the sample language in stamp format to upload into your EMR.

It is the OMA’s position that doctors’ notes for clearance to return to work or school are not an appropriate use of primary care resources. The Ontario Ministry of Health recommends against requiring doctors’ notes to clear individuals to return to school, child care or the workplace after suspected/confirmed cases of COVID-19. Nevertheless, you may still receive requests for clearance notes from patients.

Patient self-attestation form

The OMA's patient self-attestation form package is a resource that you can share with your patients. The package contains two forms:

  1. For parents and caregivers to use for their child’s return to school, child care or recreational activities.
  2. For individuals 18+ to use to return to work or school 

The package is adapted from a version previously shared by the OMA Pediatrics Section.

If a patient requests a clearance note, engage them in a conversation about the potential drawbacks of a doctor’s note for the purpose of clearance (the note will be vague, and the note is not covered as an insured service). The CPSO has confirmed that a self-attestation form may be offered to patients/parents as an option in lieu of a doctor’s note.  After the conversation, the patient may elect to use a self-attestation form instead of a note. This relieves you of your obligation under the CPSO’s Third Party Reports Policy.

However, if the patient still requests a doctor’s note over the attestation form, your obligation to prepare a note under the CPSO’s Third Party Reports Policy still applies.

Sample language for note

If the patient prefers a note instead of the self-attestation form, the following sample language may be used. Where applicable, add any detail necessary given the circumstances relevant to the situation.

I attest that based on my knowledge of the patient and the information available to me, __________________ [PATIENT NAME] meets the Ontario Ministry of Health requirements for clearance to return to [work/ school].

 

Visit OntarioMD for the sample language in stamp format to upload into your EMR.

Your role

Your role is to follow existing processes and paperwork for workplace accommodations in accordance with the Ontario Human Rights Code:

  • Complete paperwork provided by employer/insurer
  • Evaluate the patient and consider their existing workplace conditions
  • Use your clinical judgment to evaluate the request for exemption

CPSO guidance indicates that your role is to provide and attest to information about the patient’s health-care status or needs in support of a third-party process. You are not required to determine the outcome of the process (i.e. how the patient should be accommodated).

Considerations

The Government of Ontario has stated that the following people should not wear masks:

  • Children under the age of two
  • Anyone who has trouble breathing
  • Anyone who is unconscious, incapacitated or otherwise unable to remove the mask without assistance

Your role

Your role is to follow existing processes and paperwork for workplace accommodations in accordance with the Ontario Human Rights Code:

  • Complete paperwork provided by employer/insurer.
  • Evaluate the patient and consider their existing workplace conditions.
  • Use your clinical judgment to determine if the mask may present a medical risk to the patient.

CPSO guidance indicates that your role is to provide and attest to information about the patient’s health care status or needs in support of a third-party process. You are not required to determine the outcome of the process (i.e. how the patient should be accommodated).

If it is your opinion (based on the clinical evidence and information available to you) that the patient does not have a medical condition that would prevent or impede them from wearing a mask, it is your professional and legal obligation to withhold the exemption. Respectfully explain to the patient the reasons why a note cannot be provided for this purpose.

Sample language for note

For requests for exemption from wearing a mask in the workplace, the following sample language may be used. Where applicable, add any detail necessary given the circumstances relevant to the situation.

I attest that based on my knowledge of the patient and the information available to me, __________________ [PATIENT NAME] has a condition that prevents them from wearing a mask.

Visit OntarioMD for the sample language in stamp format to upload into your EMR.