Be prepared

Before the patient arrives, read through their medical notes so you are fully informed of any existing medical conditions, or medications they are taking. Reading the notes beforehand will mean there is less chance of missing an important piece of information that may be overlooked if reading the notes while the consultation is taking place.

Good communication

Most patients assess how satisfied they are with a visit to the doctor by how they were treated by the doctor during the consultation. It is not enough to diagnose and prescribe medications appropriately; you must communicate with the patient at every stage of the consultation.

• If it is necessary to conduct an examination of the patient, explain the reasons for this beforehand and outline how you will conduct the examination. Offer a chaperone, even if the examination would not normally be considered to be intimate.
• Tell patients about all the different treatment options available to them. You should recommend one option, if you think it is the most appropriate, but patients with capacity to consent to their own treatment must be made aware that they can choose a different course of treatment if they prefer. Inform patients of the risks and benefits associated with different courses of treatment.
• Give clear instructions for follow-up in case their condition does not improve with the agreed course of treatment. Let them know who they should contact if their symptoms don’t improve, or the “red-flag” signs to look out for that could indicate they need to return for urgent medical attention.

Good communication needs to extend to the entire healthcare team. Ensure everyone involved in the care of patients feels comfortable asking questions if they are not sure about their role and knows the importance of speaking up if they notice something that needs particular attention.

Good medical records

Always record all of your actions in the patients’ medical records.

• Detail any discussions you have had regarding diagnosis, treatment, examinations (and whether a chaperone was offered) and follow-up arrangements.
• Avoid abbreviations as they can be ambiguous or misleading. Imagine you are keeping notes that another clinician will need to read at some point during the course of treatment – include all pertinent details that will help the whole healthcare team to provide a good standard of care to the patient.
• If you need to add or amend any of the entries you have made in patients’ medical records, add the correction along with your initials and date; do not delete the original entry. If a complaint or claim is made and it is found that you have falsified the medical records and tried to pass them off as contemporaneous, your actions could be indefensible.
• Ensure you detail all instructions given to other members of the healthcare team in the notes, so that at any point, nurses or other doctors can refer to the notes and be brought up-to-date on what stage of treatment the patient is at. Failure to regularly check the notes can mean test results are not picked up, routine tests may not be conducted and medication errors can go unnoticed.

Follow through referrals and handovers

Trust is an integral component of the doctor-patient relationship, so always ensure you follow through with any promises you make about referring a patient for further treatment. Equally important is ensuring that when a patient is referred or handed over to the next shift of doctors, you provide all the information they will need to carry on providing treatment where you left off. This requires constant communication between yourself and your colleagues and, of course, full, detailed medical records.

Managing patients’ expectations

All consultations must be conducted with an understanding of patients’ expectations of the outcome. If you ascertain early on what they aim to get from the consultation – be it a prescription, a referral, or just a sympathetic ear – you will be better placed to ensure their expectations are realistic. You should be prepared to tell the patient what outcome they can expect from the consultation, and if it does not meet their expectations, try to offer alternatives. For example, if you don’t think their condition warrants a referral to hospital, explain your reasoning for this but tell them if there is a course of treatment you can prescribe instead.

Many complaints made to the HPCSA about medical consultations relate to costs that are incurred. Patients may be unaware that, despite subscribing to a medical aid scheme, they may be charged a fee for visiting the doctor; in some circumstances, this fee can be substantial, and can lead to the patient making a complaint.

You must always be open and honest with patients, and at the start of every consultation tell them they may be charged a fee for the consultation, even if they have medical aid arrangements in place. Always keep details of these conversations in the patient’s medical record, as they could be called upon to defend your actions if a complaint is later made.