Doctors are only human and in a busy practice or hospital environment, oversights such as suboptimal record keeping or patient management plans can occur. Often shortcomings in record keeping are highlighted in professional conduct matters and can contribute to a finding of unsatisfactory professional conduct or professional misconduct.
A recently reported case concerning a complaint prosecuted against a general physician for unsatisfactory professional conduct, illustrates how regulators consider these professional shortcomings regarding disciplinary action. The case provides an opportunity to reflect on the regulator’s decision-making process and optimal record keeping.
The physician had only recently completed Fellowship training when an elderly patient presented to the hospital in the very early morning, complaining of left shoulder pain radiating to the side of the chest. The patient had a number of pre-existing medical conditions including ischaemic heart disease and chronic back pain and had been taking opiates for the latter condition for some time.
The patient was initially assessed in the ED and then referred to the physician on the basis that the issue was considered to be a general medical one. The progression of the case was complex but in summary, after an initial oral handover between the ED doctor and physician in the early hours of the morning, the physician reviewed the patient mid-morning. Blood results indicated the patient had a raised white cell and neutrophil count. The physician concluded the cause of the shoulder pain was most likely septic arthritis and made a referral to the orthopaedic department. Antibiotics commenced mid-afternoon. The physician delegated the task of documenting the management plan for the patient in the hospital records to the resident medical officer.
The complaint alleged the physician was guilty of unsatisfactory professional conduct in the course of the direct care provided to the patient and in record keeping.
The initiation of the complaint itself and the progression of the patient’s condition over time were not apparent in the regulatory committee’s final decision. The allegations focused on the period of the patient’s care discussed above and each step of the care during this period was assessed in detail.
There were two aspects to the complaint. The first focused on a number of specific aspects of the physician’s care including the: history-taking; patient assessment and examination; diagnosis; management plan; adequacy of pain relief; timing of antibiotic administration; and the adequacy of handovers.
The second focused on the physician’s record keeping. This included concerns raised about the physician’s documentation of the aspects of care mentioned above. Specifically addressed were: the information documented in the record about the observations; the blood test findings; management plan and decision-making process that informed that plan; and the handover process. Also raised were questions about the reliance on other members of the clinical team to document.
Elements of the regulator’s decision-making process and key learnings regarding record documentation are outlined below.
Peer-review and focus on standards of care
In considering its decision, the regulatory committee that heard this case took into account the views of its clinician members and submissions from expert reviewers. Its decision-making was guided by the Health Practitioner Regulation National Law, which defines unsatisfactory professional conduct in terms of the conduct that is reasonably expected of a practitioner of an equivalent level of training or experience.
Ultimately, the committee made no findings of unsatisfactory conduct about either the physician’s practice of medicine or record keeping. The committee noted that although the physician’s record keeping was below the standard reasonably expected, it was not significantly below that standard. Each decision made by the committee about each element of the case was based on reviews by peers and other clinicians and on standards that were expected from a doctor of similar experience and training. The committee also acknowledged the doctor’s commitment to medicine and professional development and standards.
The committee stressed it was mindful of the importance of good record keeping and acknowledged some of the real-world demands on clinical teams. While commenting that some of the note keeping was scanty and suboptimal, it noted this was not a significant departure from accepted standards. The committee took into account evidence that some of the relevant documentation (such as test results) was available in other parts of the record. The committee also acknowledged the note-taking responsibilities of other members of the treatment team. Nevertheless, there were important learnings for other clinicians, particularly about documentation.
Good record keeping
When regulators are considering complaints and disciplinary actions, documentation is clearly a vital element of the evidence considered. Furthermore, less than optimal documentation, of itself, can form the basis of a complaint. Importantly, questions raised by this case centre on what messages about documentation are being emphasised for doctors in training and what is understood about this aspect of care by doctors in later stages of their careers – how can suboptimal documentation at all levels of clinical expertise be improved?
Detailed documentation can certainly be challenging for clinicians working in real-world hospital environments – where multiple busy individuals and teams are often involved in care and handovers occur and shifts change. Doctors should however keep in mind that the most important goal of documentation is to support optimal and safe patient care. Efforts should be made to document well to ensure effective communication with others in the clinical team. Important information, including from handovers, should be documented. All documentation should aim to minimise the risk of losing important elements of the history, findings, diagnoses, decisions and management plans.
Key lessons: documentation
Here are some general principles that are helpful to keep in mind:
- A record must identify the patient and include sufficient information concerning the patient’s case to allow another medical practitioner to continue management of the patient’s case.
- The level of detail contained in a record must be appropriate to the patient’s case and the medical practice concerned – this includes relevant details of clinical history, clinical findings, investigations, information given to patients, medication and other management.
- All entries in the record must be accurate statements of fact or statements of clinical judgment.
- Making and keeping a record may be delegated to a person other than the medical practitioner, but only if:
You are responsible for any records of consultations documented by junior staff on your behalf.
- the record is made and kept in accordance with the rules and protocols of the hospital, or medical service and
- the medical practitioner ensures the record is made and kept in accordance with these rules and protocols.
If you receive a complaint, contact our Medico-legal Advisory Service on 1800 128 268 for expert advice on how to respond, available 24/7 in emergencies.
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