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Too many records spoil the notes

01 January 2012

Mr M, a 51-year-old primary school teacher, was referred to ophthalmologist Mrs C, following a letter sent by an optometrist to his GP. The optometrist had found Mr M to have an abnormal right optic disc, slightly raised intraocular pressures and significant defects in the visual fields of his right eye with suspected glaucoma. Mrs C reassured the patient that the static visual field defect in the right eye was as a result of an optic disc pit and that there were no signs indicating glaucoma at that time.

Mr M then became a patient of Mrs C when he noted a deterioration in his vision. She followed him up for five years. During this period, Mr M consulted Mrs C regularly. She examined him clinically, took intraocular pressure measurements, made optic disc assessments and performed a number of investigations including serial automated visual fields tests. Mr M expressed concern about the progressive deterioration of his vision. His paternal grandmother went blind due to glaucoma and his father was on treatment for glaucoma.

Mrs C did not offer an explanation for the progressive deterioration of his sight. She did not offer a referral for a second opinion or referral to a specialist. Mr M relocated to a new town with his job and was seen by a different ophthalmologist, who found abnormalities consistent with advanced glaucoma in both eyes and significant visual field loss. Mr M was registered partially sighted and lost his driving licence. He underwent rehabilitation at work and was unable to work without the use of low vision aids.

Mr M made a claim against Mrs C. The case notes submitted by Mrs C had recorded normal examinations, which included normal pressures and normal optic discs. However, during the investigation of the case, it transpired that the documentation presented by Mrs C as her clinical notes regarding her patient were actually retyped “summaries” of the original notes.

It was found that the original notes recorded the finding of physiological disc cupping with no mention of a disc pit – yet Mrs C had failed to record the cup-disc ratios, which could have helped to monitor deterioration in the health of the discs and to ultimately diagnose Mr M’s glaucoma. It was obvious that the reproduced “summaries” – which neglected to mention the finding of physiological cupping – was an attempt to disguise the original failure to diagnose.

Expert opinion concluded that the vast majority of peers would agree that Mr M was at risk of glaucoma and that he needed to be carefully monitored with detailed recording of the state of the optic discs, and that he had signs consistent with glaucoma when he was first referred to Mrs C. They would have offered treatment for glaucoma and a referral to a glaucoma specialist for further care. The case was settled for a high sum considering the permanent and severe nature of the damage to vision.

Learning points

  • Doctors failing to make the care of the patient their first concern put themselves at the risk of both disciplinary action and medicolegal claims.
  • Disclosure of authentic, original clinical notes is essential when a claim is brought
    Early glaucoma is, unfortunately, a diagnosis that is frequently missed. All doctors are responsible for keeping up-to-date with professional knowledge, knowing their limitations and working with colleagues to provide the best level of care for their patients.
  • Listening to the patient and responding to their concerns is vital, not just for making an accurate diagnosis but also for establishing rapport and trust. Be prepared to reconsider a diagnosis that was eliminated on an earlier visit by having an open, unbiased mind at each consultation. Consider getting a second opinion if you are unable to account for a patient’s symptoms or clinical signs.
  • Medical notes have to be considered not only as medical documents but also as legal documents. Passing off rewritten records as contemporaneous is a criminal offence and any retrospective change has to be clearly marked, dated and signed, and a reason for the change should be documented. Altering existing medical records, removing records, or adding false records puts a doctor at the risk of referral to a regulatory body for dishonesty.
  • Disclosure of authentic, original clinical notes is essential when a claim is brought. Failure to do so can make a claim indefensible.
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