The LMC is regularly involved in representing and supporting doctors who have been identified as having “performance” issues. The LMC has identified a number of themes which recur, and this regular feature will highlight these, so that our members can avoid these pitfalls.

A recent case involved a GP who was reported by a colleague for adding an appointment and consultation in a patient record that did not occur.

This case was reported to NHSE and investigated.

While there may be various reasons for an appointment being added to a patient’s record that did not occur, this case highlights the importance of taking care when booking appointments and adding clinical entries into notes to ensure the integrity of the patient record is maintained. Clinicians may potentially have multiple patient records open at once while processing results, tasks or other workload, so ensuring the correct record is open is crucial.

Aspects to consider suggested by MDU to preserve the integrity of records and prevent an issue like the case outlined include:

1. Complete

Ensure your notes are an accurate reflection of what took place during a consultation and that all relevant information is filled with the patient's record.

It is usually not feasible to include every detail but recording significant negatives (as well as positive findings), your differential diagnoses and any steps taken to exclude them, can be extremely helpful.

2. Contemporaneous

Write notes as soon as possible while events are still fresh in your mind. Timely record keeping is important if colleagues need to see the patient again soon afterwards.

3. Clear and legible

When you need to make a note by hand, take a little extra time and care to write legibly so you and others can read it later.

4. Entered for the correct patient

Double-check you're saving notes into the correct patient record, especially when they have a common surname or the whole family is on your practice list.

5. Don't include ambiguous abbreviations

Some abbreviations for conditions and medication are open to misinterpretation and can confuse other members of the healthcare team. Limit them to those approved in your workplace.

6. Avoid jokey comments

Offensive, personal or humorous comments could undermine your relationship with the patient if they decide to access their records and damage your professional credibility if the records are used in evidence.

7. Not tampered with

Never try to insert new notes or delete an entry. In written notes, errors should be scored out with a single line so the original text is still legible and the corrected entry written alongside with the date, time and your signature. If you remember something significant you can make an additional note, but it should be clear when you added the information and why. Computerised entries will have an audit trail of all entries and deletions, so if something is deleted there should also be a clear record as to why that was done.

8. Checked

If notes have been dictated and transcribed by a third party, review them for transcription errors and sign entries before they are added to a patient's records. You should also check, evaluate and initial printed results, reports or letters before they are filed in the patient's records and document any appropriate action.