Clinical records can make all the difference when responding to clinical issues. Having good-quality and contemporaneous records puts you in the best possible position to explain your clinical assessments, diagnoses reached, decisions made, as well as any advice and treatment given.
If records are amended retrospectively, it can undermine the credibility when responding.
When responding to a claim, the DDU might have to recommend that a negotiated settlement be reached due to the increased risk if the member were to be put on the stand at trial.
Case examples
In one claim, a member went back through paper record cards and added additional notes to indicate that periodontal disease had been screened for, and scaling and polishing provided, along with oral hygiene instruction and periodontal disease advice.
In another complaint, a member amended a computerised entry to add more detail to a record of treatment that had later failed, with further comments on the radiographs, clinical steps taken and justification for the decisions made.
In both cases, the changes to the records created significant difficulties when responding to the issues of concern. Patient’s solicitors and the GDC sometimes ask practices to disclose audit trails from their computer systems, which will show when record entries were accessed and if they were amended.
Occasionally, this can be helpful. The DDU assisted a member who faced an allegation that they must have amended the records because they differed so significantly from the patient’s account of events. However, the audit trail confirmed that the member’s records were entirely contemporaneous, and no amendments had been made.
Unfortunately, in another case where we assisted a member, the audit trail clearly showed that the original text of the appointment in question had been significantly modified and entirely new comments added.
In rare circumstances, patient’s solicitors and the GDC can also instruct handwriting and document analysts or digital forensics specialists to scrutinise handwritten notes and computer systems.
DDU advice
It is important for a patient’s ongoing and future care that the records accurately represent what took place during a consultation, so that you and any subsequent clinicians can rely on them. Records should be made during the consultation or as soon as possible afterwards, in line with GDC advice.
When a clinician receives correspondence regarding a complaint or claim, it is common to review the records of the patient in question. Understandably, there might be concerns about the content and quality of the notes. It is common to wish that more detail had been recorded, or things had been phrased differently.
However, amending records retrospectively without making it very clear that it was done at a later point in time can backfire. It can lead to an allegation that the clinician was dishonestly representing what happened.
Sometimes it is not possible to complete a note due to time constraints, IT issues or unexpected urgent appointments. If you do not have time to complete a note during the appointment, you should do so at the earliest possible opportunity and clearly state the time that the notes or additional notes were written in the records.
Records should be made during the consultation or as soon as possible afterwards, in line with GDC advice.
If it is not possible to enter data electronically within a reasonable time period, it is good practice to make a handwritten note of the information so you can transfer it to the system when you are able to. When adding your electronic note, state the date and time that you made the paper note, the reason why you could not make it electronically and ensure the date and time being transferred to the computer is accurate.
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If you notice that your records are not accurate, for example, you realise that a detail is incorrect, such as the date of birth or tooth notation, it will be important to correct the records, but it must be entirely clear to others that this happened retrospectively.
If you are in this situation:
- do not delete or amend any existing notes from the original consultation
- flag your additional content on a newline or paragraph
- use capital letters
- include the date and time on all new content
- include the name of the clinician who made the amendment
- state the type of evidence used to make the addition, eg transcription of a handwritten note
- state the reason why the entry is being added to or amended, eg time constraints or something the clinician remembered.
If you have any queries about record keeping, there are several resources on the DDU website. You can also telephone the DDU advice line on 0800 374 626. See the DDU support pages for more information on how we can help if you've received a complaint, claim or letter from the GDC.
Greta Barnes
Greta Barnes is a senior claims handler at the MDU, with extensive expertise handling medical and dental clinical negligence claims across all UK jurisdictions, the Channel Islands, Isle of Man and Republic of Ireland. She graduated from the University of Sydney, Australia, in 2012 and joined the MDU in 2013.
See more by Greta Barnes