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Writing the visiting note: now, or maybe later?

Post date: 19/02/2016 | Time to read article: 3 mins

The information within this article was correct at the time of publishing. Last updated 14/11/2018

Dr Walter Scott FRCGP LL.B(Hons), a general practitioner and Medical Protection member working for Beacon out of hours (OOH) service on the Isle of Wight, highlights the importance of recording accurate and comprehensive notes during OOH care.

Visiting GPs, at least the good ones, have always written a consultation note when they see one of their patients at home. Traditionally, the Lloyd-George envelopes accompanied the doctor in his car and each one was then taken into the house so that the entry could be made at the bedside.

The coming of the computer age over the last couple of decades has thwarted this practice. Today’s GP takes a computer printout of recent consultations coupled with a past medical history. They may hand write an aid-memoire while still in the house and then make the formal entry on the computer when they return to his office.

So much for daytime practice, but what about the very different scenario of OOH? We have to remember that there are at least three very important differences in this relatively new situation:

  • A greater number of patients are likely to be visited in an OOH session of 5.5 hours (e.g. 18.30 to 23.59)
  • No GP records are available to provide details of the previous consultation as a starting point
  • The doctor has never seen the patient before and therefore does not have the advantage of familiarity.

It is the fragmentation of the GP service which has made an accurate and comprehensive note even more important than ever it was. We now have a situation where perhaps three different doctors will see a patient for the same illness in less than 24 hours. The handover to a different team at 6.30pm and the handback at 8am is fertile ground for a lack of proper communication.  Indeed, this is seen in its most extreme form on a Bank Holiday weekend.

It is therefore no surprise at all to see the GMC, in their booklet Good Medical Practice: Providing good clinical care saying [at paragraph 3 g.] that as a doctor you “…must…make records at the same time as the events you are recording or as soon as possible afterwards”.

All OOH organisations have a computer in the vehicle so the notes can be made just moments after leaving the house. Some have an even better system: a keyboard and screen that can be carried into the house for the note to be made at the bedside in the traditional fashion.

With a falling number of doctors trying to meet an increasing demand for OOH calls there can, at times, be some pressure to keep the vehicle moving to avoid delay. In this situation some doctors have been tempted to make no notes at all while they are with any of the patients but, rather, to make all the entries on the computer when they return to the PCC at the end of their session. 

With perhaps eight or more patients being seen in a single round of the vehicle it is very difficult to see how a note made at the end of the visiting session can claim to be truly contemporaneous, accurate and comprehensive. It goes without saying that this is essential for patient safety and is doubtless why the GMC has laboured the point so heavily.

Case study

Late one evening an OOH GP, Dr A, visited two elderly ladies with potentially serious and rather similar conditions. Dr A was of the opinion that they both needed quite urgent reassessment by their own GP’s the next morning. One of them had a very supportive family and he felt it was appropriate to leave the matter in the capable hands of the daughter-in-law, herself a GP, and meant to tick the box on the computer marked ‘patient to call own GP’. The other patient was more disabled and lived alone. Dr A thought the only safe option in her case was to arrange for the GP practice to visit promptly and meant to tick the box marked ‘Urgent review by own GP’.

Unfortunately, Dr A got confused between the two patients’ outcomes when he returned to the PCC at the end of his session to enter all his notes.  The second patient relied on the doctor’s word that he would make the necessary arrangements and did not call for help till the following evening.  When the practice doctor eventually reached the house he found his patient moribund and arranged immediate hospital admission.

Just two days later the old lady died and the family sued the practice doctor for, as they saw it, being so slow in following up the events of the previous evening. That doctor’s legal team soon joined the OOH doctor, Dr A, as second defendant on the basis that it was his negligent note keeping that had caused the delay which, in turn, had contributed to the patient’s death. 

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Please note: Medical Protection does not maintain this article and therefore the advice given may be incorrect or out of date, and may not constitute a definitive or complete statement of the legal, regulatory and/or clinical environment. MPS accepts no responsibility for the accuracy or completeness of the advice given, in particular where the legal, regulatory and/or clinical environment has changed. Articles are not intended to constitute advice in any specific situation, and if you are a member you should contact Medical Protection for tailored advice. All implied warranties and conditions are excluded, to the maximum extent permitted by law.

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