A foundation doctor had started work in a gastro-intestinal unit and accompanied the on-call registrar to see a patient on the ward. The registrar explained that they needed to carry out an endoscopy to investigate the cause of the patient’s stomach pain, but the patient refused, saying he was frightened of choking.
The registrar tried to reassure the patient about the procedure and asked him to reconsider. The registrar left promising that a doctor would see him again the next day but the patient collapsed and died that night.
The foundation doctor was saddened by the patient’s death and concerned to learn that the patient's son had angrily disputed that his father would have refused an endoscopy. Revisiting his notes to confirm his memory of the consultation, he was alarmed to discover he had not recorded the name of the registrar, and hurriedly corrected the record.
Soon afterwards the foundation doctor was called to attend a meeting with his consultant, who explained he had reviewed the records earlier and was surprised to note they had now changed. The consultant told him that the registrar, who was a locum, could not be located and warned the foundation doctor that his actions were a real cause for concern. The worried doctor called the MDU for urgent advice ahead of a meeting with the clinical director.
The adviser and foundation doctor discussed why his decision to add to his record of the consultation was problematic, even if it was done with best intentions.
While it was natural for him to be concerned about a possible complaint, amending the records retrospectively without making it clear that this was done later on was something that might be taken very seriously, as it could appear that he was dishonestly trying to cover up what had taken place.
It was important for patient care that the records authentically represented what had taken place during the consultation - and were made at the same time as the consultation or as soon as possible afterwards, in line with GMC advice. While it is clear in this case that the additions the doctor made were accurate, unexplained changes to the records at a later date can cast doubt on the integrity of the whole record, which can in turn make it harder to investigate adverse incidents or respond to complaints.
There might be occasions when a doctor genuinely believes the records are not accurate, perhaps – as in this case - because they remembered something after writing them in a hurry, or because they discovered the patient’s date of birth was wrong.
In these situations, it is permissible to add to the records, but it must be clear to others that this happened in retrospect, perhaps by stating so in clear, capital letters. The original entry should not be deleted or redacted. All additions should have the date and time of the new entry as well as the original consultation, and be signed by the person making the amendment.
It is also helpful to state the evidence used to make the note - for example, if the note is made from memory or from other written notes made at the time, such as a jobs list.
During his meeting with the clinical director, the foundation doctor explained what he had done and his intentions when amending the record. He recognised that he should have spoken to his consultant if he wanted to clarify what was in the records but that he had panicked. He also pledged to undergo additional training to improve his record-keeping.
After talking to the consultant, the clinical director concluded that the foundation doctor had been unwise but not deliberately dishonest, and was impressed that he had reflected on what had happened and was committed to improving. The trust did not discipline the doctor, but the consultant ensured his note-taking was more closely supervised.
It later emerged that the patient had confided his fears about having an endoscopy to another family member and the patient’s son did not make a complaint.
This page was correct at publication on 02/07/2021. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.