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STRAIGHT


the word “drain” in the last medical entry. She presumed this meant it could come out and agreed. However, the intended plan was to keep it in and the tick was to represent the fact that it was draining well. The patient had to have the drain reinserted under ultrasound the following day and complained to the hospital. The FY doctor making the clinical entry could have assisted their colleague by providing a more detailed medical entry. As for the doctor reviewing the entry, she accepted that it was unclear and it may have been more prudent to clarify the meaning with a senior colleague. Another, rather unfortunate case involved


an FY doctor who wrote down blood test results for several patients on peel-off labels to save time. He had intended to stick each label into the appropriate medical records, but inadvertently mixed up two of them. The patient was then deemed unfit for theatre by a consultant due to abnormal liver function tests before the error was spotted by another team member.


Take your time There is often the temptation, particularly when times are busy, to skim over relevant


parts of the clinical history, examination or management plan. This is especially likely during a busy ward round when you are expected to obtain relevant test results and arrange additional investigations at the same time as documenting the contents of the round. In circumstances like these it is important to take your time and not allow anyone to rush you. If you feel pressured, ask a senior colleague for help. Remember they have also been in your position and it is far better to seek assistance than risk making a mistake. It may also be helpful to ask the consultant or senior colleague undertaking a ward round to review your entry to ensure you have covered the key points. As well as assisting you and the ongoing care of the patient, it is in their own interests to ensure their input has been accurately documented.


Think beyond the notes The records you keep about a patient are not restricted to their medical records. They include everything from your handover sheet and list of outstanding jobs to the blood test results you have jotted down to file in the notes. Any information from which a patient can be identified is also subject to the requirement


of the Data Protection Act 2018 and General Data Protection Regulation (GDPR). You should therefore think carefully about the information you carry around about patients, how you store it, and whether it is identifiable. Once you have finished your shift and handed over, make sure you dispose of any handover or job lists securely. MDDUS recently assisted an FY doctor who


was the subject of an adverse incident investigation after throwing their handover list into the ward reception bin. The handover list noted the patients’ initials, their bed number and their outstanding medical needs. The doctor had thought that this did not constitute sensitive patient data as the patients’ full names were not used. However, when taken together as a whole, there was sufficient information to make each patient identifiable, and the Trust regarded it as a serious data breach. So while it often takes a little more time to


record an accurate, clear medical entry, the benefits in terms of risk management far outweigh the additional effort involved.


Dr Naeem Nazem is a medical adviser at MDDUS and editor of FYi


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