Section 3Medical Records
An unsatisfactory home visit MDU advice
A GP registrar returned to the practice after a The MDU adviser discussed the complaint with the doctor
week’s holiday and was asked to speak to the and advised him how best to structure a clear, open,
senior partner. The daughter of a patient he had constructive and honest response both to the senior
seen on a home visit on the day before going on partner and to the patient (and her daughter with the
leave had telephoned the practice to complain patient’s consent) in accordance with GMC guidance
about his manner during the consultation. She (Good Medical Practice,paragraph 31). The importance
indicated that her mother had felt that he seemed of a clear apology was also discussed.
to be in a hurry, had performed a perfunctory
examination of her painful hip and she remained
The new NHS complaints procedure, which started on
unclear about the diagnosis upon his departure.
1 April 2009, includes the need to agree with the
There was no record of the visit in the patient’s
complainant at the outset how the complaint will be
records and this meant the GP partner was unable
dealt with and to provide an idea of timescales for a
to respond to the patient’s daughter in the GP
response.
registrar’s absence. With regard to the omission of a note in the medical
The doctor realised that in his attempt to complete all his
record, the MDU adviser advised the member that the
practice administration before going on holiday he had
medical records should reflect the care and treatment
forgotten to document the home visit in the patient’s
provided to the patient. The adviser suggested that he
records. Fortunately no harm had come to the patient,
should record the home visit, making it clear that this
but the complaint from the daughter required a
was a later addition, by adding the date and time of the
response and the senior partner was requesting an
entry. He was advised to mark the addition with ‘added
explanation for the omission of a note in the record.
in retrospect from memory’. This would ensure that the
records were not misleading.
During the GP registrar’s leave another GP in the practice
had re-visited the patient to ensure that nothing had
The member drafted a response along the lines suggested
been missed.
which he then sent to the MDU for comment before the
final version was signed off by the senior partner as the
The GP registrar, contacted the MDU for help in ‘responsible person’ under the new complaints procedure.
responding to the complaint from the patient’s daughter He apologised for giving the impression of being off-hand
and the senior partner. during the home visit and explained that he had been
rushing to see a number of patients that day because he
was going on leave. He indicated that he would ensure
such circumstances would not impact on patient care in
the future.
The practice offered to meet with the patient’s daughter
to discuss the complaint but the daughter responded
that this was not necessary as she was satisfied with the
practice’s response, and considered that her complaint
had been resolved. The practice noted the complaint for
inclusion in the forthcoming annual report to the PCT.
The practice discussed the events at a significant event
meeting. The partners suggested that if the registrar had
felt overburdened by administration he should have
informed his trainer. It was agreed that in the future
better communication was required. The partners
discussed their own routines for home visiting and
agreed that a protocol would help ensure uniformity of
practice and avoid potential failures to record
consultations in the future. The registrar again
apologised for his failings, and acknowledged that he
had learnt lessons from these events.
“He apologised for giving the
impression of being off-hand
during the home visit...”
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