Case 3: Retrospective notes
Mr J was admitted to a psychiatric unit on 2 February 2012. He was seen by the junior doctor, Dr X, on arrival. She took a full psychiatric history, including a discussion about suicidal ideation.
However, she did not record this conversation in the notes. Mr J was discharged from hospital on 6 February 2012 and hanged himself two days later.
Dr X went back to the medical records on 8 February 2012 and, in a different coloured pen, under the entry she had made for 2 February 2012 wrote “no suicidal ideation”
Dr X went back to the medical records on 8 February 2012 and, in a different coloured pen, under the entry she had made for 2 February 2012 wrote “no suicidal ideation” – she made a retrospective note. This was picked up by the coroner during the inquest and the matter was referred to the Medical Council.
This was considered a matter of probity and the Preliminary Proceedings Committee referred the matter to a fitness to practise hearing.
All records should be contemporaneous. If you do add to a record, date and sign it and make it clear that you are adding it retrospectively. In the above scenario, Dr X, when she was made aware of what had happened, should simply have made an entry on 8 February 2012 indicating that she was aware of the suicide, and that she recollected that the patient had no suicidal ideation when she clerked him in on 2 February 2012, although she did not record this at the time.