Box 3: The importance of recording findings
An analysis of MPS cases arising from missed diagnosis of meningitis found that, in many of the cases in the sample, the patient was seen by a series of doctors before a diagnosis was made. This can make it difficult to assess the progress of the patient’s illness, so good note taking is crucial. Few of the notes in the sample recorded the patient’s temperature, pulse rate or a description of the patient’s awareness levels. Moreover, they often omitted the negative findings of clinical examinations.
Anthony, S. Don’t Get Caught in the Rash Trap, MPS Casebook 14(1): 25 (2006).