Weekly payments and the duties a worker is offered follow from the certificate. What supports the certificate sits in the note, which stays in your software.
The certificate and the note
The certificate goes to the worker, the employer and the insurer, and the insurer works from it in continuing weekly payments. The note stays in your software, disclosed only on a lawful request.
Fields differ between states, territories and the Commonwealth scheme, so work from the current form published by the scheme you certify under.
What the note has to carry
- 1. The mechanism in the worker's own words: date, place, the task, and what they did immediately afterwards.
- 2. Whether they reported it and to whom, and any treatment given before they reached you.
- 3. Prior history of the same body region, whether or not it assists the claim.
- 4. Dated objective findings: measured range, graded power, gait, swelling, neurological signs, or their documented absence.
- 5. Investigations reviewed, and the reasoning connecting the findings to the restrictions certified.
- 6. The worker's actual job tasks, any duties list you relied on, what you advised and when you will review it.
- 7. For a certificate covering a period already passed, what the worker reported about the intervening weeks and who else treated them.
Reasoning behind the certified capacity
If you certify four hours a day, the file needs to show why four and not six: the sitting tolerance reported, the sedating effect of medication, or an expected healing timeframe.
Work relatedness is an opinion formed from the history given and the findings made, and a mechanism consistent with the presentation on examination is a defensible clinical statement.
Good medical practice, the Medical Board of Australia's code of conduct for doctors, requires doctors to be honest and not misleading in certificates and to verify the content before signing. Some schemes place conditions on backdating.
Restrictions in workplace units
Light duties carries no measurable limit, and the case manager or supervisor who translates it commonly resolves it into no offer of work, or an offer well outside what you intended.
Certify the capacity that remains. A certificate of no capacity carries a shorter review interval and its reasoning in the note. Naming an individual on a psychological injury certificate makes a clinical detail a workplace document, so keep the detail in the note.
- Hours per day and days per week, and whether they increase across the certificate period.
- Weights with a height and a frequency: five kilograms from waist height occasionally is not five kilograms off the floor repeatedly.
- Postural tolerances with a duration, such as minutes of standing before a change of position.
- Named prohibitions: no ladders or work at height, no driving heavy vehicles, no repetitive reaching above shoulder height.
- For psychological injury, environmental restrictions stated functionally: no sole charge shifts, no work at a named site, or scheduled breaks.
Suitable duties and the employer
Ask the worker to take you through a shift: the heaviest thing they lift and how often, how much of it is on their feet, what machinery they operate. Record who sent any duties list and which parts you relied on, and name any duty outside the restrictions with the functional reason.
Weekly payments run to the end of the certified period, so confirm an appointment exists inside it before the worker leaves.
Insurer requests for the record
Most schemes give the insurer a statutory ability to obtain medical information relevant to the claim, and the claim paperwork usually includes an authority the worker has signed. Requests also arrive by subpoena. Under the Australian Privacy Principles disclosure of health information needs consent or another lawful ground, so record the ground you relied on.
An authority covering a claimed shoulder injury does not reach obstetric history, unrelated mental health care, or consultations predating the injury. Ask for a broadly drawn request to be narrowed before anything leaves the practice. Scope, redaction and subpoenas: responding to a request for clinical records.
Audit trails make a note edited after a request arrives visible as an amendment, so correct a wrong entry by dated addendum and leave the original readable. Where an independent examination differs, take the history again, examine, and document what changed.
- A certificate carrying restrictions where the note records no examination that day.
- A certificate stating the injury is work related where the history describes onset at home.
- Restrictions unchanged across six months of certificates while the notes record steady improvement.
- A telehealth certification where the note does not say what the assessment was based on.
Documenting the consultation with aurii
With consent, aurii records the consultation and drafts a structured note: the mechanism in the worker's own words, the examination as performed, the discussion about job tasks, and what was agreed. The draft is available at the end of the appointment.
aurii does not complete the certificate and certifies nothing. The treating clinician remains responsible for the clinical content. Clinical safety.
Your letterhead and section order, set once, on every draft. The template set. One is a work certificate, which carries the diagnosis, the certified capacity, the restrictions and the review date into a document you edit and sign.
A rehabilitation consultant, support person or interpreter in the room is captured too, so consent covers everyone present.
How the injury happened in the worker's own account, dated objective examination findings, any earlier trouble with the same body region, the worker's description of the job they do, and a sentence linking those findings to the hours and restrictions certified. The certified period should run to the next review appointment, and that appointment should already be booked.
In the units a workplace rosters by: hours per day and days per week, weights with a height and a frequency attached, postural tolerances in minutes, and named prohibitions such as no ladders or no repetitive overhead reaching. Say whether the hours are meant to step up across the certificate period.
Usually yes, within limits. Australian schemes generally allow an insurer to obtain medical information relevant to the claim, and the claim paperwork normally carries an authority the worker has signed, but a request framed around a shoulder injury does not reach the rest of the chart. Note which authority you acted on and what you sent, and take advice from your medical defence organisation before answering a subpoena.
This is general information about documentation in workers compensation consultations. It is not clinical or legal advice.