NOTICE BOARD BLOG


retrospectively. There lies the way to jail and serious GMC sanction. In circumstances where the patient or


By Dr Gail


Gilmartin, Medical and Risk


Adviser at MDDUS Records – friend or foe


Consider this scenario – several months after a consultation a patient complains to the GMC that you behaved inappropriately during an examination. You robustly deny these allegations and immediately review your records for the relevant period. You are horrified to find that there is only the briefest entry regarding a cough and clear chest on examination. You have one of those “if only….” moments. There are no witnesses and so to ascertain the truth the matter proceeds to a panel hearing at the GMC. You consider that the quality of the


records lets you down but you must deal with this honestly and openly in any future discussions – and there will be many. Certainly the records must not be altered with a view to “improving them”


their representative challenges the standards of care, medical records will be scrutinised by various third parties. Also patients increasingly seek access to their notes – because they are just interested or they require information for purposes such as checking dates for insurance forms, etc. Most practitioners do not consider


that their records will be seen, analysed and discussed in minute detail by third parties such as solicitors, barristers, medical experts or panel members (for inquiries including the GMC). Medical records will be obtained and


reviewed when determining whether a doctor has acted in line with their professional and legal duties. Indeed, the first impression you make is likely to be through your records – the care demonstrated in record making will often be taken as a direct reflection of the care provided to your patient. Would you be happy for your notes to be shared and discussed amongst a group of expert lawyers and doctors? Are you happy for the patient to see what you have written? The GMC states that notes must be:


• Detailed


• Clear • Accurate • Legible. They should be dated and timed, and contain all clinically relevant information including negative findings and decisions. Few (if any) doctors say they wish they


hadn’t written so much but many reflect that they wish they had written more. This is especially true where a patient brings two issues to a consultation and one is well documented but the other less so; also when a standard form of treatment is considered and rejected but this is not recorded. The matters not included in the


records are often central to a question of standard of care and it is very frustrating when the notes do not corroborate what is remembered, as referred to in the scenario set out above. Medical records are a window onto


your practice and as well as containing information directly relevant to patient care they are central evidence of standards of care. How would your records stand up to


scrutiny or help you in your hour of need? This blog was published first on the MDDUS Risk Blog website at http:// riskblog.mddus.com/. Access the site for other interesting topics.


sponsor of the event and category sponsor for Primary Care Team of the Year. The Union’s chief executive Professor Gordon Dickson delivered the welcome


speech as almost 700 guests gathered to applaud the 60 teams shortlisted in 13 categories. Taking the award for Primary Care Team of the Year was the Emergency Care


and CPD. It can be purchased at the online RCGP shop.


l NEW ESSENTIAL GUIDES MDDUS has published two


SUMMER 2014


Practitioner Scheme in West Leicestershire which aims to reduce the numbers of “urgent call” patients transferred to hospital. The title of Emergency Medicine Team of the year went to the Rapid Resuscitation Response Unit, Emergency Medicine Research Group, in Edinburgh. The unit works 24/7 to improve prehospital resuscitation practice, attending more than 85 per cent of all out-of-hospital cardiac arrests in the area. The Karen Woo Surgical Team of the


Year award was presented to Surgical Telementoring in Tanzania. Under the programme, surgeons at Northumbria Healthcare NHS Foundation Trust provided


new Essential Guide booklets offering overviews and brief advice for members on coroner’s inquests and fatal accident inquiries. The new


intensive training and telementoring to surgeons at Kilimanjaro Christian Medical Centre. Patient Safety Team of the Year was Great Ormond Street Hospital NHS Foundation Trust in London, while Bipolar Education Programme Cymru won Innovation Team of the Year. The Lifetime Achievement Award winner


was Sir Iain Chalmers. He founded The Cochrane Collaboration which works to produce accessible, evidence-based health information free from commercial sponsorship. For a full list of all the winners visit http://groupawards.bmj.com


Essential Guides can be accessed in the Publications section of www. mddus.com


l DENTAL PRACTICE FOI UPDATE NHS dentists in Scotland must update their publication scheme


now to comply with freedom of information laws. A notice was sent out reminding practitioners to renew their current 2010 scheme by June 1. The ICO is advising dentists to visit www.itspublicknowledge.info/MPS for detailed guidance.


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The Medical and Dental Defence Union of Scotland | Protecting you since 1902


The Medical and Dental Defence Union of Scotland | Protecting you since 1902


Essential guide to the coroner’s inquest Essential guide to the fatal accident inquiry


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