The scenario

An FY1 doctor was completing a patient's discharge summary and reviewing the patient's hospital notes. The doctor had clerked the patient when they arrived on the ward with chest pain. During her review of the patient's admission notes later, she realised she hadn't included details of the patient's physical observations, which were within the normal ranges on the observation chart.

She'd documented her examination findings of the patient's cardiovascular system, but had also omitted her findings of the patient's respiratory system, which she recollected was normal.

There was sufficient space for her to add the missing information in the relevant section in her clerking notes, and she felt the omitted information should be recorded in some way, but was unsure how to do this. She contacted the MDU advice line for guidance.

MDU advice

The GMC's 'Good medical practice' (2013) states that patient records (and any formal records where you record your work) must be "clear, accurate, contemporaneous and legible" (paragraph 69). The GMC's updated guidance comes into effect on 30 January 2024, and explains that "you should make records at the same time as the events you are recording or as soon as possible afterwards" (paragraph 19).

The MDU adviser explained that she could make an additional retrospective note to include the missing information, but it should be clear when she added this information and why. This way her honesty could not be called into question.

What's more, records should never be overwritten, inked out or deleted. Under data protection rules, patients have a right to request rectification of data where it is factually inaccurate or incomplete, such as a misspelt name. However, this does not extend to clinical opinions that the patient disagrees with and that are considered to have been validly held at the time the contemporaneous note was made.

Outcome

After discussing their case with the MDU adviser, the FY1 doctor realised it was not appropriate to add the missing information in the relevant section of the clerking proforma. Instead, she made a retrospective entry in the patient's records detailing that she had realised the information was missing when she was completing the patient's discharge summary.

She documented the physical observations she had seen, making it clear that she was referencing the observation chart she'd been able to review. She also documented her respiratory examination findings, adding that these were based on her recollection.

This is a fictionalised case compiled from actual MDU case files.

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