Don't Forget the Notes!

Case history

A patient was diagnosed with a depressed skull fracture after he fell five metres during a scaffolding collapse at a worksite. He was admitted to the neurosurgical unit where he was assessed by the neurosurgical fellow and prescribed Tramadol by Dr Nice, a senior medical resident at the hospital.

The following morning, a ward round was conducted by Dr Nice and intern, Dr Caress. Dr Nice determined that the patient's Glasgow Coma Scale was 15 and subsequently changed his drug regime from Tramadol to Codeine Phosphate. Dr Caress made notes of the ward round in the clinical record; however he did not include the author of the notes or the results of the physical examination.

Early in the afternoon, in response to the patient's increasing pain, Dr Nice prescribed Panadeine Forte and Endone. After a further review at 6.00pm, Dr Nice charted morphine as a PRN medication. She did not intend for both Morphine and Endone to be administered to the patient but that they be given in the alternative. Dr Nice did not make this distinction clear when she charted the medications as: Panadeine Forte (2 tabs QID), Endone (5mg 1 tab q4/24, PRN) Morphine (5mg QID PRN).

Dr Nice finished her shift at 7.00pm. When she returned to work the following day, she was informed that the patient had been found unresponsive at 2.30am and that CPR had been attempted unsuccessfully. Dr Nice was advised that a hospital investigation had commenced and that the Coroner had been notified.

Discussion

The Medical Board of Australia's Good Medical Practice: A Code of Conduct for Doctors 1 (the Code) states that maintaining clear and accurate medical records is essential for the continuing good care of patients. According to the Code, good medical practice involves keeping accurate, up-to-date and legible records that are sufficiently detailed to facilitate continuity of patient care.

In this case, both Dr Caress and Dr Nice failed to make a detailed entry in the medical record. Dr Caress did not include results of the physical examination and importantly, he did not record the entry in his own name. When Dr Nice subsequently reviewed the patient in the afternoon, she failed to chart the medications as she intended. As a result, there was a risk that the patient would be administered excessive opiate medication because the full clinical history of the patient was not clear from the entries in the medical record.

While professional regulations for medical records differ from state to state, the Code provides specific guidance on making, storing and accessing medical records. The provisions of the Code are comparable to the Health Practitioner (New South Wales) Regulation 2010 which is considered a good reference for all practitioners. According to these regulations, a medical record should include:

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• the date and person making the entry
• information relevant to diagnosis and treatment e.g. history, physical examination, mental state, results of any test, allergies
• clinical opinion
• plan of treatment
• any medication prescribed
• information or advice given to the patient in relation to any medical treatment
• details of any medical treatment, including any
  medical or surgical procedure.

If Dr Caress and Dr Nice had made good clinical notes it would have assisted in the investigation into the cause and circumstances surrounding the patient's death. It would have also significantly improved the defensibility of any claim or complaint subsequently brought by the patient's family.

JMOs are encouraged to examine their skills in this area of medical practice and consider using the regulations as a reference when making entries in the medical record. If you are involved in a similar incident and would like advice on the investigation process and how to respond, contact our 24 hour Medico-legal Advisory Service on 1800 011 255 or email advice@mdanational.com.au.

References
1 Good Medical Practice: A Code of Conduct for Doctors in Australia. Available at: medicalboard.govu.au/Codes- Guidelines-Policies.aspx