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Doctor’s good medical records key in patient care and defence

11 March 2019 | Avant media

The primary objective of medical records is the safe and effective care of patients1 but they can also protect your reputation, as one physician member discovered after a patient lodged a complaint with AHPRA.

His experience provides an example of how AHPRA determines its findings and why adherence to the Good Medical Practice: A code of conduct for doctors in Australia (the Code of Conduct), must be evident in your records.

The case

The patient was diagnosed with metastatic colorectal cancer, a serious condition with a high rate of relapse. In order for the chemotherapy treatment to commence, the patient required an implantable port for central venous access, which was inserted with his consent. The management plan included 12 chemotherapy treatments on a fortnightly basis. This treatment was successful.

Following completion of the treatment, which was uneventful, a decision was made, with the patient’s agreement, to leave the implantable port in due to the high risk of relapse. Consequently, the patient required regular monitoring and flushing of the implantable port. The latter were performed by oncology nurses.

After three years of regular monitoring and no reported issues, a problem with the implantable port arose. The physician was contacted by the nursing staff and immediately arranged for the implantable port to be removed. Unfortunately, during the removal of the implantable port the patient suffered a complication, namely fragmentation of the implantable port. This is an uncommon but well recognised complication.

In his complaint, the patient alleged the physician failed to adequately flush/drain the implantable port, which resulted in a complicated removal of the implantable port. He also expressed concern that the implantable port was left in-situ for three years which, as he understood, was inappropriate.

What did AHPRA consider?

During the initial assessment of the notification, the Board considered whether or not the physician provided safe and effective medical care and whether there was evidence he posed a risk to the public.2 Two issues were raised, namely:

  1. Whether the physician had provided adequate treatment in relation to the management of the patient’s implantable port
  2. Whether he had caused a delay in the removal of the implantable port.

On assessing the quality of care, consideration was given to the management plan, specifically to the section of the Code of Conduct which states that providing good patient care includes formulating and implementing a suitable management plan.1

What the records showed

The medical records confirmed the physician had explained the rationale for keeping the implantable port in place to the patient and that the patient had agreed with this course of action.

The records also confirmed that as soon as the physician was made aware of the implantable port dysfunction, its removal was arranged immediately.

In his submission to AHPRA, the physician explained the rationale behind leaving the implantable port in situ - which was that there was very high risk of relapse of the cancer and if this occurred, it would be treated most likely with chemotherapy again. He explained that removing and re-implanting the implantable port would mean an unnecessary procedure, and cause inconvenience, for the patient. Therefore he considered it appropriate to recommend, as he does for all patients in similar situations, leaving the implantable port in situ. He further stated that the trigger points for implantable port removal were major pain, difficulties with flushing or clotting, or change in the position of the device which were not initially present. When the problems with pain and difficulty flushing the implantable port were brought to his attention, appropriate steps to arrange its removal were taken.

Avant’s assistance for the member

Avant’s medico-legal team successfully assisted the member in responding to the complaint and supported him throughout the process. They helped him identify the relevant issues and prepare his response to the notification. Both the doctor and the legal team worked together on finalising the submission to AHPRA.

The decision

Upon consideration of the submission and the medical records, the Board decided to take no further action. The Board accepted the clinical rationale for leaving the implantable port in situ following completion of the chemotherapy treatment was appropriate.

In response to the patient’s concerns regarding the delay in removal of the implantable port, the Board stated that this implantable port could have remained in situ for at least five years as long as it continued to function adequately. Although the complication is unusual, the Board also noted that fragmentation of an implantable port is a recognised complication of the removal procedure. Ultimately, the Board concluded there was insufficient evidence to suggest the fragmentation was due to the length of time the port had been implanted. It also concluded the physician did not cause any delay in the removal of the implantable port as he made an urgent referral to have the implantable port removed as soon as he was notified of the issues.

In these circumstances, the Board considered the physician had implemented an appropriate management plan for the patient. Ultimately, the Board decided the physician’s performance was appropriate and no further action was taken.

Key lessons

When regulators are considering complaints and disciplinary actions, documentation is a vital element of the evidence.

Good medical records are a must – the Code of Conduct1 summarises this as “Keeping accurate, up-to-date and legible records that report relevant details of clinical history, clinical findings, investigations, information given to patients, medication and other management in a form that can be understood by other health practitioners.” Specifically:

  1. Consents must be recorded.
  2. Medically appropriate actions should be documented.
  3. Records must follow correct protocol for notification of patient progress and facilitate transfer of clinically relevant information between care providers.

More information

Download our factsheets, Medical records – the essentials and Consent essentials.

Complete our eLearning course: On the record: medical records and documentation.

If you receive a complaint, call our Medico-legal Advisory Service on 1800 128 268 for expert advice, available 24/7 in emergencies.

References

1 Good medical practice: a code of conduct for doctors in Australia

https://www.medicalboard.gov.au/codes-guidelines-policies/code-of-conduct.aspx

2 The National Registration and Accreditation Scheme

http://www.health.gov.au/internet/main/publishing.nsf/Content/work-nras

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