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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.
In view of this fact it is essential that a Doctors' notes are beyond repproach. They may very well be his only source to turn to recall the facts and treatment of a case.
Medical notes should:
Identify the patient, record initial finding, test procedures, support the diagnosis, document the course of treatment effects, promote continuity of care amongst healthcare professionals. The notes should be a rich source of information when required for audit, research or for the Criminal and Civil courts and/or for the coroner or complaints department. The entries must be signed, dated, legible, unbiased, concise and legible. Also the very simple things like putting the patients name and hospital number at the top of every page.
This is a tall order for a busy doctor but no allowance is given by courts for 'lack of time' to complete notes.
Bear in mind that the Doctors medical notes illustrate to a court (at least in part) the quality of a Doctors care.
The notes I read daily for medicolegal reasons have several common themes which almost invariable arise:
1. Illegible writing
2. No time/date entry given for an entry made
3. Medical entry contains no clear signature or'rank' or 'dept' of person making the entry
4. No written reference made regarding results of radiographs or other texts in the notes
5. Doctors writing defensively
6. Offensive references made about the patient
7. Signs that entries have been altered when a marked error has been highlighted.
8. Failure to record that advice was sought from another Doctor by telephone
9. Any information shared with the patient.
10. Failure to record that a patient had been referred to another speciality (and the time)
Remember that almost always patients can read their notes - never write anything in the notes
that you would not be happy for the patient to see.
Prescriptions also have their problems, particularly they are often written illegibly (although most now seem to be computer generated). In a very well known case (Lee v Prendergast) a GP prescribed Amoxil for his patient. At best the prescription was a scrawl. The pharmacist decided that he prescription said Daonil. The patient took the medication over several days and suffered severe brain damage. The Doctor and Pharmacist were both found guilty and blame apportioned.
I am sorry if I am telling anyone how to suck eggs but believe me this is a very real problem. A superd Doctor can be exemplary clinically but can have his professional name scorched by poor record keeping.