Casebook Vol. 17 no. 2 - May 2009
Head of Medical Services (Leeds), Dr Nick Clements, introduces this issue’s round-up of case reports, which highlight the importance of taking an adequate history and good record keeping
Back to basics is a phrase that can be overused in everyday life, but it is a vitally important concept for the medical practitioner. Taking a patient’s history and listening to what they are telling you are key to any diagnosis. Equally, an over-reliance on the outcome of previous consultations may prevent you from maintaining an open mind about that patient’s symptoms.
The case on page 17 demonstrates the need to go back to the beginning when symptoms persist in the face of continuing treatment, both in taking a history and examining the patient. Good record keeping is another basic tenet of good medical practice. Several of the cases included here highlight the negative impacts of keeping poor records when attempting to show that good practice has been followed. The case on page 20, however, demonstrates that, even where the outcome of a case may be tragic and unavoidable, good records are evidence of the high standards of medical care given.
Another theme which is demonstrated by cases in this issue is the importance of being aware of your limits, and of your responsibilities in this respect. It can be difficult to say no in certain situations, particularly when you are new to a department, but your responsibility for a patient’s welfare is paramount. You may be keen to prove your competence, but that does not mean that you should be afraid to ask for advice from senior colleagues when you are unsure of how to proceed with care.
Linking all of these areas is the importance of effective communications, whether written or verbal. Good communications are a vital part of medical practice, and encompass listening skills and body language, as well as the way you express yourself to others. Developing and maintaining these skills will help you to build good relationships and to understand the concerns of colleagues or those of patients and their relatives.
What's it worth?
Since precise settlement figures can be affected by issues that are not directly relevant to the learning points of the case (such as the claimant’s job or the number of children they have) this figure can sometimes be misleading. For case reports in Casebook, we simply give a broad indication of the settlement figure, based on the following scale:
- High £1,000,000+
- Substantial £100,000+
- Moderate £10,000+
- Low £1,000+
- Negligible <£1,000
Casebook publishes medicolegal reports as an educational aid to MPS members and to act as a risk-management tool. The reports are based on issues arising in MPS cases from around the world. Facts have been altered to preserve confidentiality.