Take Care When Amending Medical Notes, Warns MDDUS, Scotland

Main Category: Litigation / Medical Malpractice
Also Included In: Primary Care / General Practice;  Dentistry
Article Date: 08 Jun 2009 - 8:00 PDT

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Doctors must take care when amending medical notes to avoid potential charges of tampering with evidence, warns the Medical and Dental Defence Union of Scotland (MDDUS) today.

For the purposes of evidence, medical notes are expected to be contemporaneous - made on the day and at the time given, the MDDUS points out in its June eMonthly. Notes must be clearly dated, with no suggestion that they were made earlier, unless that is clearly specified.

There may be an innocent explanation why a doctor did not make a note at the time stated, but unless that is made clear, suspicions may arise, damaging the doctor's credibility and - at worst - leading to allegations of tampering. MDDUS has acted on behalf of doctors in such cases who faced the criminal charge of attempting to pervert the course of justice.

A GMC fitness to practice hearing may also result, leading to suspension or erasure.

Late entries on medical record are not unusual, for example when a GP sees a patient but cannot immediately make notes, perhaps because a computer is not readily available.

A doctor may also wish to expand on notes whilst a consultation is fresh in his or her mind. Occasionally MDDUS has also encountered significantly re-written notes for more distressing reasons, such as the catastrophic spilling of coffee or another beverage on a case file.

Computers do show when notes are made but doctors should not rely on this to confirm times and dates - the accepted practice is that both are specifically recorded on notes.

"Whenever you add to notes, it makes sense to record the date and time," says Dr George Fernie, head of the medical division of the UK-wide MDDUS. "You never know when it might prove important. If amending notes looks like tampering, the results can be serious."

MDDUS is a medical defence organisation providing access to professional indemnity and expert medicolegal advice for doctors, dentists and other healthcare professionals throughout the UK.

Source
Medical and Dental Defence Union of Scotland