[This article is part of the "Avoiding easy mistakes: Five medicolegal hazards for junior doctors" booklet. To download the booklet as a PDF or read more click here
Good Medical Practice advises doctors that they must be honest and trustworthy when signing forms, reports and other documents. It also requires doctors to make sure that any documents they write or sign are not false or misleading
"Junior doctors [must] inform the GMC if they have accepted a caution, been charged with a criminal offence, or if they have been found unfit to practise by a professional body"
This means that doctors must take reasonable steps to verify the information in the documents, and must not deliberately leave out anything relevant. You may encounter families who don’t want certain information visible on the death certificate, but doctors have a legal and professional obligation to complete the certificate truthfully.
Falling under this category is the requirement for any junior doctor to inform the GMC if they have accepted a caution, been charged with a criminal offence, or if they have been found unfit to practise by a professional body anywhere in the world. It also includes the requirement to take up any post that you have formally accepted.
- If you are uncertain double check your work with a senior.
- Take steps to verify what you are saying. Never sign a form unless you have read it and you are absolutely sure that what you are saying is true.
- Probity means being honest and trustworthy and acting with integrity.
- Be honest about your experiences, qualifications and position.
- Be honest in all your written and spoken statements, whether you are giving evidence or acting as a witness in litigation.
- You must be open and honest with any financial arrangements with patients and employers, insurers and other organisations or individuals.
- Assume that all records will be seen by the patient and/or others, eg, GMC, court.
Dr T is in the second week of his surgical training. Following a successful cholecystectomy, Dr T is delegated the responsibility of writing up the operation notes from the surgery. He gets to work immediately, but in his haste he forgets to write up the postoperative instructions for hourly urine output monitoring, and continues to work through his list of patients.
"In his haste he unfortunately forgets to write up the postoperative instructions
A few hours later the patient experiences problems so he visits her again, and realises the mistake on the records. Dr T alters the records to include what he had previously omitted. Dr A, a registrar, saw Dr T alter the record.
Dr A confronts Dr T about his actions, but Dr T pleads with him not to say anything. Dr A calls MPS for advice. A medicolegal adviser suggests that Dr A raise the matter with Dr T’s consultant or supervisor. Dr A does this, and Dr T receives a stiff word from his consultant, who addressed it as a training issue. If his actions were to be repeated, Dr T could face disciplinary action.