Dr Rachel Birch, medicolegal adviser at Medical Protection, shares a recent case on documenting a patient’s aggressive behaviour in his medical record.
Mr D, a practice manager, telephoned the Medical Protection medicolegal advice line to seek advice on a challenging situation.
Mr T had attended a routine diabetic review appointment with Mrs S, the practice nurse. As part of the usual process, Mr T was asked about his smoking status and his weekly average alcohol consumption. He had become distressed at the questioning and started shouting.
Mrs S tried to defuse the situation, but Mr T swore, stood up and kicked his chair across the room. He immediately apologised, becoming tearful and explaining to Mrs S that he was under a lot of pressure at work. Mrs S felt safe to continue the consultation. In fact, Mr T was able to share some of his frustrations about how his diabetes affected him day to day, and Mrs S was able to provide him with helpful advice.
The following day, the incident was discussed at a practice meeting. Mrs S felt that Mr T’s aggressive behaviour should be documented in his medical record, but other clinicians disagreed. Mr D was asked to seek advice from Medical Protection.
Mr D called Medical Protection and spoke to Dr K, an expert medicolegal adviser who had worked for many years as a GP.
Dr K advised Mr D that clinical records must be clear, accurate and contemporaneous and should include relevant clinical findings.1
It is important to document in the patient’s medical records any information pertinent to the patient’s health. This is essential so that the patient receives an accurate diagnosis, appropriate treatment and good continuity of care.
Dr K went on to point out that there may be circumstances where aggressive behaviour could be a symptom of a physical or mental health illness. Failure to document behaviour in this regard could potentially lead to a delay in diagnosis and patient harm.
Mr D stated that Mrs S was concerned that Mr T’s behaviour could be relevant to his health and that was why she wished to document it in his medical record. Dr K advised that when patients are aggressive during a consultation, the clinician should decide, on a case by case basis, whether and how to document such information in the medical records.
Any information regarding a patient’s behaviour should be documented in a factual and non-prejudicial manner.
Any information regarding a patient’s behaviour should be documented in a factual and non-prejudicial manner. Inappropriate personal opinions of a patient should be avoided. For example, a factual description of the words used, tone of voice, use of gestures and posture is more helpful than just stating that a patient was rude and aggressive.
- If a patient’s behaviour is likely to be relevant to their health, then it should be documented factually within the medical record.
- When patients have displayed aggressive behaviour, discuss whether practice staff could be at risk from future episodes. You may wish to consider placing an alert on the patient’s records to inform staff of the behaviour.
- If incidents arise outside the context of a consultation, consider whether the behaviour needs to be documented in the medical records or not. On occasions you may feel it is sufficient to place an account of what occurred in an incident log. It is also possible to then put a note within the consultation record for example, “incident logged in practice file…”
- There are circumstances in which it would be more appropriate to document any incidents with a patient in a separate folder. Such circumstances might be where a patient has made a complaint against the practice and the patient has become upset or angry (but not violent, aggressive or abusive) during a local resolution meeting.
- Remember that information about a patient stored outside the records would still be required to be disclosed, on request by the patient, under data protection legislation.
To contact Medical Protection with your own query, contact our 24/7 helpline on 0800 561 9090.
1) GMC, Good Medical Practice (2013)