Medico-legal - Documenting non-clinical factors

Record non-clinical factors clearly and accurately, says MPS adviser Dr Jayne Molodynski.

It is important to remember any notes made on medical records may be seen by the patient
It is important to remember any notes made on medical records may be seen by the patient

Keeping good clinical records is essential for patient care. The GMC expects doctors to keep clear, accurate and legible records.

The main purpose of keeping records is to provide continuity of care; however, they are also important for audit, research and medico-legal purposes.

Appropriate comments
It may sometimes be necessary to document information which may not appear to be clinically relevant.

For example, if a patient is aggressive, it may be relevant to document this to inform other members of the healthcare team so that necessary precautions are taken to ensure the patient receives appropriate care.

It is important to ensure that any record of this type is factual and objective. Any notes made in the medical records should be written with the expectation that they will be viewed by the patient or their legal representative.

A GP should keep an open mind about these patients, as unusual or aggressive behaviour may be related to underlying pathology.

Unfortunately, inappropriate comments are sometimes recorded in a patient's records. In the past, abbreviations were occasionally used to make derogatory comments about patients. This practice is now rare.

However, from time to time, disparaging remarks about a colleague or a patient's previous management are made. This is not only unprofessional but can also have serious repercussions for the patient, and sometimes for the doctor.

For example, a GP asks a consultant colleague for a second opinion about a patient's management. The doctor reviewing the patient makes inappropriate comments in the records about the GP's provisional diagnosis and treatment.

The patient subsequently makes a complaint about an unrelated issue; however, she requests a copy of her medical records and sees the comments made by the consultant - these could lead to an unjustified complaint to the GP, or a complaint about the consultant's actions.

GMC guidance
GMC guidance states: 'You must not make malicious and unfounded criticisms of colleagues that may undermine patients' trust in the care or treatment they receive or in the judgment of those treating them.'

If you have concerns about a patient's management, you should discuss these with the doctor involved. It may be that you were not aware of the relevant clinical information when you reviewed the case, and that your initial concerns were unfounded.

Alternatively, your colleague may welcome your advice and the opportunity to reflect on the decisions they have made. Pursuing this course of action will ensure that valuable learning opportunities are not missed.

If you have ongoing concerns about a colleague's performance, and you are concerned that patients are at risk of harm, the GMC expects doctors to take appropriate steps to protect patients. You should give an honest explanation of your concerns to an appropriate person from your employing or contracting body, and follow their procedures.

Removing patients from practice lists
Another difficult area is the removal of patients from a practice's list. There is extensive guidance available on this issue from medical defence organisations, the BMA and RCGP.

Essentially, GPs need to have reasonable grounds to remove a patient from their list, for example, when the patient has moved outside the practice boundary. Practices must follow the procedures set out in their contract with the PCT.

Irretrievable breakdown of the doctor-patient relationship is used to justify removal.

However, where possible more specific reasons should be given.

Patients should never be removed because they have made a complaint; however, multiple or malicious complaints can lead to a breakdown in the doctor-patient relationship.

If a patient's behaviour is deemed to be unacceptable - for example, if they use obscene language, they should be advised about this and given an opportunity to improve their conduct.

If the behaviour persists, and the practice decides to proceed with a removal, then the patient should be informed in writing. The practice could be criticised if no warning was given in the preceding 12 months.

Patients should also be given information about how to register with a new GP and the PCT needs to be informed.

It is now possible to request the immediate removal of a patient if they have been violent. The police must be informed and the patient and the PCT notified in writing. It is also a requirement of the GMS contract to record the removal of the patient and the circumstances leading to it in the medical records.

Unfortunately, removing patients often leads to complaints, which is one of the reasons it is important to follow correct procedures and make detailed records explaining this decision. In addition, it may be prudent to seek further advice from your medical defence organisation.

  • Dr Molodynski is a medico-legal adviser at the Medical Protection Society
Learning points
  • Any notes made in the medical records should be written with the expectation that they will be viewed by the patient or their legal representative.
  • It is important to document any unreasonable behaviour by the patient and the steps taken to address this.
  • Doubts about a colleague's treatment decisions should not be recorded on medical records. It is better to talk to your colleague instead.
  • If in doubt, seek further advice from your medical defence organisation.

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