Forums » Open clinical » Medicolegal » Are medical notes the best armour in my defence of negligence?
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Are medical notes the best armour in my defence of negligence?
posted at 1/12/2011 12:06 PM GMT
on bmj.com
Moved from the General clinical forum
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Posts: 958
First: 15/7/2011 Last: 15/5/2013 |
Think about the patients you have treated in the last decade. I presume there will be several thousands cases you have had some input into. The Statute of Limitations for negligence is generally three years but a Judge can extend that if he sees fit. Anyone unfortunate enough to have a claim of negligence made against them will know how long, arduous and stressful it is. But they usually do not realise that because of the antiquated way the law works (despite it being revamped in the 1990s) the average time for a claim of negligence to get to court is seven years. |
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Re: Are medical notes the best armour in my defence of negligence?
posted at 1/12/2011 8:42 PM GMT
on bmj.com
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Posts: 2947
First: 10/3/2009 Last: 29/4/2013 |
I agree. I find few entries in charts where the actual thinking behind the management is stated as a few lines in well constructed prose. All too often it is a log of observations and sometimes treatment rather than a bird's eye view of the problem, the cerebral stuff behind the pulling of levers and as for comments on prognosis, well they are rarely stated. Years later when it comes to law, the thinking behind the gear pulling and button pushing is vital. There seems to be a reluctance to go beyond the charting of just observations for reasons that escape me as I always do this. RMOs almost never do it as they think this is the job of the boss to write the big picture stuff but this is wrong in my opinion as every act is the result of thinking. Having your full name in PRINT on the top of each entry can save the nurse calling the wrong doctor at night as well. I not only put down the date but always the exact time as this may one day save your bacon.
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Re: Are medical notes the best armour in my defence of negligence?
posted at 2/12/2011 7:36 AM GMT
on bmj.com
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Posts: 2034
First: 12/3/2010 Last: 17/5/2013 |
The above have pointed out that let alone years, just days later, the notes are your ONLY information about the patient's management, either yours or that of others and your ONLY defence to protect you if accused of negligence. So what am I to do, if I don't have the patient's notes? Not because they are new to the Hospital, but because the Hospital has lost trace of them. Not an occasional pt. but many. It is routine for me to see complex cases for assessment of their anaesthesia risk, and the notes of half or more of them have been lost. Sometimes for ever - they have a 'temporary folder' in which is the entire history of their present complaint, including their surgeon's remark that the old notes have been lost. Sometimes so recently that investigations requested by the surgeon who has referred them to me, in the knowledge that they will be helpful, are not available. I have access to computer systems that allow me to see previous pathology results, correspondence and special investigation reports, but Gosh! they are time consuming to consult! And I can't see previous anaesthesia records or the letters or reports from tertiary referrals, so I know nothing about cardiac or neuro events, ar even periop. events in my own hospital. Patients even arrive for elective surgery with none of their old or recent notes available. How much can I rely on this routine negligence (?) by my Hospital, if I am sued by a patient? Almost continual complaint, the issuing of a "critical incident" report for every time that notes are missing, and pressure through managment channels makes no difference. I'm tempted to refuse to see in clinic, or to refuse to anaesthetise a patient whose record has been lost, but Gosh! again, there would be so many! And so far, I and my collegaues have got away with it. But for how long? JOhn |
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Re: Are medical notes the best armour in my defence of negligence?
posted at 2/12/2011 10:48 AM GMT
on bmj.com
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Posts: 3
First: 30/11/2011 Last: 2/12/2011 |
This is very interesting post, and this is a true and real problem, Have anyone been in a surgical rotation? MOstly it the most junior doctor is the one writing in the notes, and the time spent per patient is around 2-3 minutes (this is absolutley true) in a ward round you see 20 patients in something around 40-50 minutes. So how much do you think one can end up writing? The problem is there is a true pressure in the hospitals, there is to many patients, to many clinics, to few staff and real true pressure to be quick and at the same time safe and being able to be excellent in one profession. In norway they came up with an excellent solution which is; everytime we see a patient in the ward round we have a dictaphone were we voice record everything fairly quickly, then after the ward round this dictaphone is given to a typist that writes it down in office an prints it out within few hours, so the quality of the notes of the ward round is very very excellent. Wish we have that in UK. Another solution is like what king college is doing, everything is computer written this way it is very clear and you can easly serach in the medical notes. In my personal openiun writing in paper in this time and age is very very old style and the profession i think demands a more modern and better solution. Just ask anyone, the medical notes are often if not always (not to say low level) not as high level as the what happends in the ward round it self, a lot is lost. |
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Re: Are medical notes the best armour in my defence of negligence?
posted at 2/12/2011 9:25 PM GMT
on bmj.com
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Posts: 10
First: 20/10/2011 Last: 5/2/2013 |
In Response to Re: Are medical notes the best armour in my defence of negligence?: This is very interesting post, and this is a true and real problem, Have anyone been in a surgical rotation? MOstly it the most junior doctor is the one writing in the notes, and the time spent per patient is around 2-3 minutes (this is absolutley true) in a ward round you see 20 patients in something around 40-50 minutes. So how much do you think one can end up writing? The problem is there is a true pressure in the hospitals, there is to many patients, to many clinics, to few staff and real true pressure to be quick and at the same time safe and being able to be excellent in one profession. In norway they came up with an excellent solution which is; everytime we see a patient in the ward round we have a dictaphone were we voice record everything fairly quickly, then after the ward round this dictaphone is given to a typist that writes it down in office an prints it out within few hours, so the quality of the notes of the ward round is very very excellent. Wish we have that in UK. Another solution is like what king college is doing, everything is computer written this way it is very clear and you can easly serach in the medical notes. In my personal openiun writing in paper in this time and age is very very old style and the profession i think demands a more modern and better solution. Just ask anyone, the medical notes are often if not always (not to say low level) not as high level as the what happends in the ward round it self, a lot is lost. Posted by AhmedTalib Agree but no fool proof solution dictaphones are commonly used on ortho consultant ward rounds. While clear notes are generated, often the turn round time for these notes is long, compromising communication between teams. This is particularly a problem in joint patient care- 'the orhopods have been but written nothing, too busy in theatre to answer bleeps'. Full computerisation sounds good. However IT systems keep breaking down and paper backup comes handy. In addition, often not enough computers when needed. Taken up by people chasing bloods, doing TTAs name it. Besides logging in can take ages. The time factor comes in! My recent experience with electronic TTA + discharge summaries : it takes much longer to do them, causes delays in discharge, not flexible. Perhaps safer? I don't know. Having clinical correspondence, including previous discharge summaries electronically accessible certainly goes a long way where notes are unavailable! |
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Re: Are medical notes the best armour in my defence of negligence?
posted at 2/12/2011 9:52 PM GMT
on bmj.com
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Posts: 575
First: 8/6/2011 Last: 14/5/2013 |
I think the best way when you examenine a patient is to write simultaneusly everything on the paper or pc ' cause of comming, clinical findigs, paraclinical examinations etc And before you decide about the final diagnosis and the treatment you can look on the paper and you see all the picture again. These is very good and for double check ! It is very difficult to make a mistake or forgot sommething if every time , before finishing , you check your notes. It is best and for the patient's outcome becouse if he commes again or other doctor continiues with him ' the notes will be very helpfull. |
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Re: Are medical notes the best armour in my defence of negligence?
posted at 4/12/2011 3:14 PM GMT
on bmj.com
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Posts: 958
First: 15/7/2011 Last: 15/5/2013 |
How much can I rely on this routine negligence (?) by my Hospital, if I am sued by a patient? Almost continual complaint, the issuing of a "critical incident" report for every time that notes are missing, and pressure through managment channels makes no difference. I'm tempted to refuse to see in clinic, or to refuse to anaesthetise a patient whose record has been lost, but Gosh! again, there would be so many! And so far, I and my collegaues have got away with it. But for how long? JOhn Hi John D, You rightly see the above as extremely troubling. NHS Trusts have a legal obligation to maintain and store safely all patient records. In my view you correctly use the term 'negligence' and it appears to be almost endemic. Have you raised this issue in writing at the highest level within the Trust?. The tragedy here is that if a patient were to suffer harm or death due to an anaesthetic agent or procedure which was forseeable had the notes been available, the person in the doc taking the rap would be the humble anaesthetist. Certainly, management may face corporate manslaughter charges but the court would be asking the question: Doctor, you are experienced and skilled in the complex field of anaesthesia, why did you undertake to put this patient to sleep when you did not have before you the patients full medical history and anaesthetic record which would elicite the patients previous responses to anaesthesia?. It would not be good enough to say, well frequently entire notes or parts of notes are missing so we carry on regardless. I really had no choice. |
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Re: Are medical notes the best armour in my defence of negligence?
posted at 5/12/2011 8:51 AM GMT
on bmj.com
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Posts: 20
First: 27/9/2011 Last: 13/1/2012 |
Ahmed Talib raises a good point: on a ward round, if the senior doctor is clinically examining the patient and the junior is recording this, if a problem arises in the notes, whose fault is it? The senior may have examined completely, but the junior failed to appropriately record this. |
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Re: Are medical notes the best armour in my defence of negligence?
posted at 14/12/2011 7:39 AM GMT
on bmj.com
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Posts: 336
First: 12/7/2010 Last: 14/5/2013 |
I have to admit, I was surprised when I saw the handwritten notes of doctors inside patient files in India. Most hospitals in the Gulf have computerized patient files so I was really impressed when I saw the lovely cursive handwriting of the Indian doctors, who meticulously outlined their patient histories (95% of them were legible, and……sort of pretty). It really felt like they were going that extra, caring mile.
Although the computerized system has its advantages (takes care of a LOT of your stated problems kirked eg: issues 1,2,3,4,7,8,10), a lot of doctors seem to take it for granted. For instance, a consultant once observed that a lot of the notes seem “old”, as busy doctors tend to copy and paste what was initially written at the A&E with a few, if any, modifications. And a lot of doctors are notorious for using abbreviations that only they can decipher (might stand true for the "writers" and "typers").
The computerized system covers all aspects of the history and automatically takes care of the names of doctors on the patient case (you need to log in to enter data). It also prevents manipulation of patient data and provides a comprehensive patient e-file complete with radiological, lab, management and follow up options. It also includes recorded input from the multidisciplinary staff and that’s really good for legal purposes. Doctors simply print out the relevant sheets for discussions in morning meetings and then send them to the shredder. Some eco-friendly departments use projectors during morning meetings so that the printing and shredding task is bypassed. Once you are oriented to the system, it becomes a seamless task navigating when presenting. Also on rounds, the doctors present from their personal notes/hospital laptop but any recommendation for further tests/medications made by the consultants are immediately entered on the spot into the laptop. Lab values are also easily re-checked (even newly released results) from the portable laptop which travels with the group. So once the rounds are over, everything has been recorded into the computer.
If I were to be realistic, I think we should use the computerized system fully for what it’s worth. Our job has become so much easier so why should one get lazy on the easy? I do admire the writing approach but its cons outweigh the pros (illegibility, loss of records etc). The biggest flaw, of getting complacent with recording and pasting old histories in the computerized system need to be addressed however. Technical glitches are few if the system is well maintained (we did have laptops crashing in the middle of entering data), but the overall benefits of typing over writing makes them forgivable, in my opnion. |
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