Articles and Case Studies

Close Encounters of the Patient Kind

01 Dec 2017

by Dr Brian Morton

Doctor doing hospital rounds at patients' bed

How well do you document your patient encounters? I don’t just mean consultations, but all encounters including telephone calls, emails and dual consults on a ward round with registrars, residents or interns.

The case

Mrs X had two to three episodes of dysphasia reported by her family which were brief and she recovered fully. Her GP who was consulted 24 hours after the last episode found no abnormality. Some 36 hours later she was admitted to hospital with a CVA. Her family submitted a complaint that her GP should have diagnosed a TIA and referred her on for investigation. Furthermore, they alleged that the GP had not performed an appropriate examination.

The Medical Board, on receipt of the complaint, requested the GP to respond and supply the record of the consultation.

It’s important to understand that the complaint and initial response are dealt with on the written statements of the doctor and the documentation provided. It’s at this point that the complaint will proceed or fail. The documentation of that encounter will support a decision of no further action or lead to further proceedings.

The documentation 

For this hypothetical case, the GP did have computer entries of history and examination. There was no management plan documented. The GP’s statement indicated a verbal plan given to the patient and family member present. 

Reviewing the notes, the history documented the word dysphasia, the past history was noted, and the examination was documented with BP recorded and “neuro intact, walking normally”. 

The GP’s statement indicated a more detailed history and examination. This represented a significant divergence from the family’s written complaint which also alleged that no advice was given for further management. 

The investigator’s point of view 

Play the above scenario as if you were an investigator looking at the evidence presented. In the history, wouldn’t you expect to read a record of the episode duration, confirmation with the patient and family that it was a true dysphasia, and questions about other neurological accompaniments such as sensory or motor symptoms? Is there documentation of the examination: power, tone, reflexes, cranial nerves, cardiac rhythm? Would you also expect a documented plan of further management, such as a referral for an ECG and carotid duplex?

The importance of records 

Adequate documentation needs only to be simple and basic with relevant pertinent details which evidence appropriate clinical input. It’s also important to indicate your diagnostic thinking. 

The reality is that during our careers, we may all have a complaint made against us. The reality check is that bad things do happen to patients whether preventable or not, and patients and families want an explanation or sometimes need to blame someone or something. 

Even if you mentally go through a differential diagnosis and use experiential shortcuts to arrive at a provisional diagnosis, it is important to document that process, albeit in a brief but appropriately recorded manner. 

When two or more versions of an encounter are presented, your documentation provides a contemporaneous record of the accuracy of your version. Remember, if there are multiple presentations there is likely to be a disparity in the histories taken, but good records will confirm your version of the content of the consultation. 

Simple entries, perhaps using SOAP (an acronym for subjective, objective, assessment, and plan) headings in your electronic record – history/examination/ diagnosis/plan will aid in ensuring you have adequately documented the consultation and protected yourself.

Complaints and Adverse Events, Medical Records and Reports
 

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