Do you ever have that ‘ooh err… not happy about those notes’ moments… when you look at something recorded by a clinician and think that there isn’t quite enough detail there to cover your back if the ‘you-know-what’ hits the big fat fan?! I have what you might call a medico-legal ‘bent’ (long story, won’t bore you with the details) and so when we have a significant event, or I hear of a complaint from a patient, my first point of call is the medical record to get the background and see what was written at the time of the alleged ‘offence’. It might be that I need to audit trail a prescription, or see if what the patient said reflects accurately what the GP did (or didn’t do) before I go to that GP/nurse/receptionist to get their comments.

More often than not, the information I need to either add to the SEA, or start to resolve the complaint is there within the records. However, on occasion it isn’t – and that might be for a variety of reasons – amongst those, clinician/a.n.other was rushing, over-running, forgot to add the detail, or perhaps they just didn’t record it in the first place.

I had a situation recently where the parent of a toddler declined for their child to have a particular vaccination, as is their right to do so.  Unfortunately, a couple of days after the visit to the surgery, the other parent made it quite clear that they weren’t aware of their spouse’s decision. They complained that they should have been made aware of the decision as they shared parental responsibility (the spouse actually being an ex-spouse). Cue lots of discussions with the patient’s GP and the nurse involved… and me sweating in my office muttering s**t, s**t, s**t under my breath!   It became clear whilst talking to the nurse that in fact the parent hadn’t declined as such, but just wanted more time to think about it and possibly book later. The nurse though hadn’t documented this part of the conversation. She had recorded all the immunisations given but a simple omission led to more problems. It wasn’t that she had deliberately done this, just hadn’t thought of it at the time – and then of course, a few patients later, it got forgotten.

If a record of that conversation was there in the notes, it would have been clear to see – but in this case, it wouldn’t have made the outcome any different. The other parent would still have been as p***ed off with their ex, as they were already – but it highlighted an issue regarding note taking.   I have been involved with some fairly hairy cases over the years where the content of medical records has literally saved the day, and in one case unfortunately it rather left the GP hung out to dry. I’m not saying that we need War and Peace entries in the records, but if something isn’t wanted or hasn’t been done, that can be as important in the records as saying it IS wanted or needs to be done.

And then, as if I didn’t have enough to deal with, at the SEA that followed one GP expressed her dissatisfaction with this “new system… can’t we go back to Lloyd George… it never used to be this anal.”   You can just hear it, can’t you? “I can’t keep up with these bloody changes, it was never like this before…bureaucracy, red tape, moan/groan/whinge.”  Short of telling said GP to just shut up and toe the line (because everything we have to do now is not the same as everything we did back in the 1980’s), I just sat there, nodding my head, like the Churchill Dog, agreeing that it was shocking, but sign o’ the times etc. Part of me gets where she’s coming from, but the other part of me is thinking I can’t help defend you if you don’t write it in the flippin’ notes!

So, what do we do? Well, in this case, a group discussion as part of the SEA brought it home to both the nurse and the doc that actually, where notes are concerned, contemporaneous records are the done thing. It’s no good trying to defend yourself two years down the line in a Court of Law saying “well, of course I remember that Mum/Dad/Grandma said they would go away and think about it…” because that just won’t wash with the prosecuting barrister and if it isn’t written down, it didn’t happen!

I think the GP may decide to retire sooner rather than later, and if I was any better off, I’d be joining her!

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