The GP Support Team at Londonwide LMCs have been involved in several cases over the last few months in which a GP has got into difficulty on the basis that they have retrospectively amended the records in a non-transparent way.
The cases have usually involved an adverse outcome and whilst it has been the case that the GP was simply amending the records to more widely reflect what they recall was discussed at the consultation, amending records in this way inevitably raises probity concerns.
The purpose of this guidance is to describe how a GP can retrospectively capture discussions that occurred at a consultation, which were not recorded at the time, without leaving themselves open to criticism.
What the GMC says (and does not say) about contemporaneous record keeping
The GMC state in the guidance entitled Good Medical Practice (paragraph 19) (the emphasis is added):
You should* make records at the same time as the events you are recording or as soon as possible afterwards.
*Note: the GMC are contemplating using the term must rather than should in the next version of Good Medical Practice (which is currently out to consultation).
The GMC do not prescribe a time frame that would fulfil the definition of as soon as possible thereafter, however this does allow some leeway to account for circumstances when it is not possible to record the consultation contemporaneously (for example – in the context of a late visit).
Furthermore, the GMC do not provide any guidance as to in what circumstances it would be appropriate to amend the records and/or make a retrospective entry and/or how this should be undertaken.
When it is acceptable to retrospectively amend the records and how it should be done
Londonwide LMCs have previously provided guidance in relation to amending the records: Amending medical records – appropriate circumstances and how it should be done
When making entries in the records you must bear the following matters in mind:
- You must always do so under your own login (as an aside, you should keep your login details confidential and always remember to log off at the end of a session or if your terminal is unattended and may be accessed by others).
- The audit trail will clearly demonstrate when records were made and altered and under whose login.
- Whilst it is unlikely that you will be reasonably criticised for correcting minor typographical errors (which do not alter the meaning of the entry) or completing the record immediately after the patient has left the consultation, you should not rely on the audit trail as an objective way to demonstrate that the record has been amended (beyond these examples).
- You must only make a retrospective entry and/or amendment to the records to reflect the discussions that took place – you should not seek to embellish the records to include matters that were not discussed.
When retrospectively adding more detailed notes to the patient’s record, the record should include (in a way that is immediately apparent to an objective reader):
- The name of the person adding the information.
- The time and date of the addition.
- An explanation of which information has been added.
- An explanation of why these were not recorded at the time of the original entry and why they are being entered now.
The other alternative would be to leave the original entry unamended and make a fresh entry in the records, referencing the original entry and following the above principles. You might wish to consider adopting this approach if you are making the entry some considerable time after the original notes and if you do adopt this approach, you might wish to add the following form of words to the original entry:
Please see associated entry on [insert date amendment was added]
Seek professional advice
If there has been an adverse incident which has caused you to review your records, then you should seek professional advice (either from the GP Support Team at Londonwide LMCs or your medical defence organisation) before making a retrospective entry in the records.
Other sources of evidence
You should be reassured that even if you do not feel that your contemporaneous record captured all that was discussed at a consultation, in the event of a complaint, claim etc, some reliance may be placed on your recollections of the consultation, together with your usual practice. Although in the absence of an entry in the record or other evidence (such as a colleague who may have been present in the consultation) the Courts have tended to prefer the evidence of the patient when the facts of what occurred during the consultation are disputed.
If the consultation was undertaken over the telephone, you should check as to whether the call was recorded (and if so whether you can still access the recording, or a transcript of the discussion).
If there has been an adverse incident, then a Significant Event Analysis (which would be disclosable in the event of a claim and should be drafted with that in mind) can be a useful way in capturing what was discussed in the consultation and how the original record did not capture the discussion in full (as an aside, one of the learning points would be how to make it easier to capture the full discussion in the records).