Drs Note

[Sushirolls]

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Patient relapsed on alcohol.
Bed date in a few days for residential.
Wants a note from work for the few days leading up to admission.
Thoughts?

 

[Old&InTheWay]

Does the employer know they are going to residential treatment? Strange that they would even care about the few days before. But I would write a note for someone who is seeking treatment; they're taking care of themselves and potentially not having a job to return to could be detrimental.

Am I missing something? In what way are you struggling with it?

 

[Sushirolls]

Why the person isn't using sick days?
Nuances of substance use as illness and medical protections in the eyes of federal government, i.e. can you write a letter that states this person is "sick."
People can't get FMLA protections for SUDs, 'oh no I had relapse today guess I need to use my FMLA allowed time for my cocaine relapse' but protections exist by the ADA for doing AA/NA meetings and the like, and also for treatment.
Since the person isn't in treatment yet, and likely to be drinking, should that be protected by a dr note?

 

[Sushirolls]

Ultimately, I've opted to request the patient come in for appointment, get more details, then write a note for that day of appointment and ensuing days until the tentative residential admission. All of this is less than 7 days.

 

[Stagg737]

Why the person isn't using sick days?
Nuances of substance use as illness and medical protections in the eyes of federal government, i.e. can you write a letter that states this person is "sick."
People can't get FMLA protections for SUDs, 'oh no I had relapse today guess I need to use my FMLA allowed time for my cocaine relapse' but protections exist by the ADA for doing AA/NA meetings and the like, and also for treatment.
Since the person isn't in treatment yet, and likely to be drinking, should that be protected by a dr note?

Unless this is a person with a h/o not showing up to treatment or significant non-compliance issues I'd give them the benefit of the doubt if they're actively seeking treatment and have planned admission for residential treatment. I guess asking why they don't use sick days is a valid question, but what's the harm/liability of providing a note to excuse the pt for 3-4 days before entering treatment if the patient is asking for this? By not writing the note it could be assumed that you feel they're functional enough to keep working, which may be more annoying to justify than just excusing them for a couple of days.

 

[Bartelby]

In this context I also agree with writing a note (seeking treatment, just a few days, does damage control which may aid long-term sobriety).

 

[Sushirolls]

So the consensus is to write the note, which I intend. But what about the nuances of Laws, protections, etc. I.e. where are the forensic minded people. What do they say?

 

[calvnandhobbs68]

So the consensus is to write the note, which I intend. But what about the nuances of Laws, protections, etc. I.e. where are the forensic minded people. What do they say?

What? What are you talking about?

People literally get doctors notes for days off of work for all kinds of random stuff. I can go to my PCP saying I’ve got severe migraines and get a note saying I can’t go back to work until Monday no problem. **** I could probably do a telemedicine visit with some urgent care, tell them I’m crapping my brains out from some unspecified gastroenteritis and get them to write that I can’t come back to work for a few days.

 

[Sushirolls]

What? What are you talking about?

People literally get doctors notes for days off of work for all kinds of random stuff. I can go to my PCP saying I’ve got severe migraines and get a note saying I can’t go back to work until Monday no problem. **** I could probably do a telemedicine visit with some urgent care, tell them I’m crapping my brains out from some unspecified gastroenteritis and get them to write that I can’t come back to work for a few days.

As you should. GI and Migraines are a Medical illness. That's established. Its what doctors do. You write the note.

People don't get notes for having a bad day feeling triggered, getting plastered, and saying, "Doc, I really have a bad hang over. Can you write me a note for my hangover? Oh, and for yesterday, because I was too intoxicated to work and stayed home."

This is the nuance I am trying to get at. The line of substance use disorder, intoxication, withdrawals, etc and where can we write a note?

The law recognizes that there aren't job protections for people showing up intoxicated at a work place, you get fired. You have a migraine and say I'm leaving home, get a doctors note, you get protections for that. Drink at work, and say I'm going home to finish the bottle, you don't get protections with your employer. See what I'm trying to tease out?

 

[Stagg737]

People don't get notes for having a bad day feeling triggered, getting plastered, and saying, "Doc, I really have a bad hang over. Can you write me a note for my hangover? Oh, and for yesterday, because I was too intoxicated to work and stayed home."

This is the nuance I am trying to get at. The line of substance use disorder, intoxication, withdrawals, etc and where can we write a note?

I would hope that if they are entering inpatient treatment for alcohol, that they'd have a substance use disorder which I would imagine would be considered a medical illness. Going through withdrawals should certainly be covered as it can justify medical admission. I guess intoxication without a SUD could be questionable. I would be interested to hear about laws involving that, though I'd suspect that it would be very state-dependent.

As an aside, I have seen docs write notes for hangovers when students reported vomiting or other symptoms, though I don't know if they told the docs that they were drunk or hungover.

 

[clausewitz2]

ADA offers protection for SUDs and sees them as a disability. It does not, however, apply to active substance use or intoxication. Thus accomodations for treatment 100% legit, accomodations for being plastered not so much.

 

[erg923]

Patient relapsed on alcohol.
Bed date in a few days for residential.
Wants a note from work for the few days leading up to admission.
Thoughts?

So....your patient wants a "work note" for why he/she was on a etoh binder for a "few days" rather than working? Is that right?

I don't care what your stance is on "disease" or not. No. The reality/idea of "natural consequences" is often necessary, if not extremely helpful for facilitating SUDs recovery. Denial...and all that. I would not get involved here. All you can really say is that they willfully decided to drink a bunch of alcohol despite knowing better/not to (unless you think they are psychotic). And how helpful would that be? And how would that make you look?

 

[FlowRate]

Regarding the sick days comment, my understanding is FMLA just guarantees that your job is safe, not that you're paid for the time. Plenty of places make you use your sick time if you want to be paid for any of your FMLA time off. (Please correct me if this is wrong.)

 

[Taddy Mason]

Regarding the sick days comment, my understanding is FMLA just guarantees that your job is safe, not that you're paid for the time. Plenty of places make you use your sick time if you want to be paid for any of your FMLA time off. (Please correct me if this is wrong.)

Correct. FMLA just assures your job is protected for up to 12 weeks. Pay would have to come from sick days/PTO or short-term disability.

 

[Ironspy]

Some employers require a doctors note to use sick days

 

[Old&InTheWay]

This is the nuance I am trying to get at. The line of substance use disorder, intoxication, withdrawals, etc and where can we write a note?

The law recognizes that there aren't job protections for people showing up intoxicated at a work place, you get fired. You have a migraine and say I'm leaving home, get a doctors note, you get protections for that. Drink at work, and say I'm going home to finish the bottle, you don't get protections with your employer. See what I'm trying to tease out?

I am not aware of any laws per se that dictate when doctors can write notes. ADA regulations that protect employment are kind of irrelevant in regards to our interactions with patients, correct?

I think this gets back to the fact that doctors' notes are pretty stupid and not medically necessary in general. So I think you can take one of several general approaches: 1) write anyone who asks a generic note, 2) write no one a note ever, 3) only write notes for patients who are contagious or for whom work would exacerbate the current medical condition.

I don't think that whether a condition is self-inflicted is useful in this decision as this can apply to many medical conditions (e.g. lung cancer 2/2 smoking, DKA 2/2 poorly controlled diabetes, MI 2/2 too many hamburgers, psychosis 2/2 non-med compliance, relapse in a pt with OUD) and I can't think of how this principle could be applied in a generalizable manner.

 

[calvnandhobbs68]

I am not aware of any laws per se that dictate when doctors can write notes. ADA regulations that protect employment are kind of irrelevant in regards to our interactions with patients, correct?

I think this gets back to the fact that doctor's notes are pretty stupid and not medically necessary in general. So I think you can take one of several general approaches: 1) write anyone who asks a generic note, 2) write no one a note ever, 3) only write notes for patients who are contagious or for whom work would exacerbate the current medical condition.

I don't think that whether a condition is self-inflicted is useful in this decision as this can apply to many medical conditions (e.g. lung cancer 2/2 smoking, DKA 2/2 poorly controlled diabetes, MI 2/2 too many hamburgers, psychosis 2/2 non-med compliance, relapse in a pt with OUD) and I can't think of how this principle could be applied in a generalizable manner.

Right this is exactly my point. There's no LEGALITY to doctors notes and the question about legality just doesn't make much sense. A doctor's note is basically just saying "hey this person seems sick to me and I don't think they'd be able to come back to their work for X period of time". It's up to the employer about what to do with that. Different doctors have wildly different thresholds for what they'll write notes for. Most people do view them as kind of a "customer service" thing and if you ask for a note for a random few days off work and have some semi-legit medical reason, don't really see the harm in writing them.

Yes, if you're certain the only thing the patient is doing is going on a 3 day drinking binge for the time period you're writing the note, fine probably not super healthy to enable that. Alternatively, if the patient is trying to avoid stress exacerbating drinking behavior and showing up to work drunk which may get them fired and willing to hang out with family/friends for those few days to try to avoid further relapse or spending that time preparing themselves for residential rehab (getting all their stuff at home in order, pets taken care of, etc), what's the harm in that?