Following are answers to pediatricians’ questions about providing “medical clearance” to patients in the era of COVID-19 and handling patients who refuse to wear masks.
Q: I’ve received several parent notes asking for medical clearance for child care, return to school and athletic participation for children who are recovering from minor respiratory illness or COVID-19 infection. What can I do to minimize my liability risks when handling these requests?
A: Recent reports suggest that 40% or more of pediatric COVID-19 infections may be asymptomatic, with most symptomatic children having mild, nonspecific complaints. Without widely available rapid testing, physicians will find it difficult to differentiate COVID-19 from other common respiratory illnesses.
Despite this, physicians will be asked to help determine when children can return to regular activities and to provide written documentation indicating medical clearance. Physicians should rely on Centers for Disease Control and Prevention (CDC) guidelines regarding the duration of quarantine following known COVID-19 exposure or infection, https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html.
Q: What about patients who need medical clearance under less clear circumstances such as well patients seeking medical clearance for participation in activities or sports, children with nonspecific respiratory symptoms or recent removal from school or child care for transient fever, or patients without symptoms who may have been exposed to COVID-19?
A: Medical clearance has no specific legal definition and typically means different things to the physician and parent. In the case of possible COVID-19 illness, the community may perceive medical clearance as a guarantee of health and safety for others from exposure. The mild or asymptomatic nature of COVID-19 in children makes this assurance impossible.
In addition, clinical information on the potential impact of SARS-CoV-2 on children continues to evolve, e.g. recent descriptions of myocarditis in children with mild SARS-CoV-2 symptoms, as described in the AAP interim guidance on return to sports, http://bit.ly/AAPsportsguidance.
Inform parents of the risks and the joint nature of the decision-making about activity participation. Adding a disclaimer note may provide some additional liability protections for pediatricians asked to document medical clearance: “Based on current practice guidelines, physician examination, history and any appropriate testing, no obvious reasons for exclusion from (the activity) have been identified. Reasonable medical standards indicate that the child may participate, but the parents must consider the child’s individual risks and benefits of participation and understand that clearance is not a guarantee against adverse outcomes or future medical problems.”
Q: What should I do when parents request a note exempting children from wearing a cloth face covering or mask?
A: It is important for pediatricians to convey that masks can be worn safely by nearly all children 2 years of age and older, including the vast majority of children with underlying health conditions, with rare exception.
You may want to create a template form for patients who may not be able to wear masks safely in schools or other settings due to underlying health conditions. The documentation can provide guidance and encourage alternative protections such as barriers, distancing, access to handwashing and sanitizers, which may minimize claims of acquired infection due to appropriate avoidance of masks.
Q: What should I do if parents refuse to wear masks in my office?
A: This creates a Catch-22. Do you allow the potential for others in the office to be exposed to illness, or should the patient be turned away, leading to a possible allegation of abandonment?
The majority of states have issued some form of mask mandate based largely on recommendations from the CDC, Occupational Safety and Health Administration and medical organizations such as the AAP. You can minimize your liability by establishing and following office policy based on their guidance.
Clear practice protocols will help the practice and staff address unmasked parents or patients and should identify rare situations when cloth facial coverings can be withheld due to a medical or developmental condition.
Use appointment confirmation calls, office signage, website notices, email blasts and social media to notify parents prior to arrival that masks are required. Offering a free mask at the front desk may resolve the problem.
To avoid allegations of abandonment, ill patients without masks may require an office assessment to determine if the medical appointment is needed urgently that day or if a telehealth visit is an option.
Practices also should carefully consider their ongoing care of patients who place other patients and providers at risk by refusing to mask during a deadly pandemic. If dismissal from the practice is considered, follow state regulations and insurance contracts.
Practice management pointers
- Follow recommendations from recognized national organizations for return to activity or sports when they are appropriate to the clinical situation. Find AAP interim guidance at http://bit.ly/AAPsportsguidance.
- Tailor forms to your practice to improve efficiency. Add a disclaimer on all medical clearance forms related to return to child care, activity, school or work environments. Have your legal adviser review forms to ensure their applicability to state and local laws.
- Implement a clear policy for patients over 2 years old and parents who enter your facility without a mask. Empower staff to follow the protocol, and back them up by enforcing the policy. Develop a safety plan on how to respond if someone becomes belligerent or threatens staff.
- Be aware that information about COVID-19 is changing rapidly, and recommendations may change as the medical community learns more about transmission and the consequences of exposures.
- Consult your state and local public health officials for guidance.
Dr. Scibilia chairs the AAP Committee on Medical Liability and Risk Management.