Casebook Vol. 22 no. 3 - September 2014
From the case files
This edition Dr Mark Dinwoodie, head of member education at MPS, assesses the key learning from the latest collection of case reports
I’m delighted to have the opportunity to reflect on the cases in this edition of Casebook from an educational and risk management perspective. The cases of Mr D, with his osteoarthritic knees (“A pain in the knee”), and Mrs H, with her neuropraxia following cannula insertion (“A cannula complication”), remind us how record-keeping can contribute to an effective defence against allegations of negligence. Of course, good documentation is also increasingly essential to support good clinical care and enable continuity to be delivered by an increasing range and number of involved healthcare professionals.
It is important that not only should the clinical assessment and any procedure be adequately documented, but also the discussion behind any decision made regarding treatment. It is, of course, a matter of judgment regarding how much to write in the notes and, inevitably, time pressures will contribute to that consideration.