It was a foundation doctor's turn to record the consultant’s morning ward-round. After listening to the chest of a patient with acute severe asthma, the consultant noted he could hear a wheeze on both sides and recommended nebulised salbutamol, oxygen and steroids, and a review in two hours.

Distracted by a sudden noise, the doctor missed what had been said and she only wrote 'asthma, nebulised salbutamol and review' in the records. Later that day, the patient suddenly deteriorated and x-rays revealed a severe pneumothorax. He was given an emergency chest drain and transferred to a high dependency unit, where he made a full recovery.

On reviewing the clinical records, the consultant was critical of the doctor for not making an accurate note of the consultation, particularly his findings on listening to the patient's chest and the plan to review in two hours. He complained the doctor's poor record-keeping could lead to an accusation that he had missed a life-threatening condition and added he had concerns about her communication during patient handovers.

Concerned she was being blamed for what happened, the foundation doctor called the MDU for assistance.

What happened next

After listening to the doctor's account, the medico-legal adviser reassured her that most significant events are investigated and concluded without blame being put on individuals.

At the same time, it was important for the doctor to reflect on the experience and what it had taught her. They agreed that the doctor needed to improve her note-taking and discussed the GMC's guidance on record-keeping in 'Good medical practice' (2024) (paragraph 70), which sets out what should be included. But it was equally important to record significant negative findings as well, for example, recording that chest pain was not exertional would help exclude angina.

The doctor wanted to know whether it was possible to amend the entry to show what had occurred but the adviser explained this could give the impression the records had been deliberately tampered with. This would have even more serious consequences because it could be perceived as dishonest.

After speaking with the MDU, the doctor spoke with her educational supervisor and wrote a reflective piece about the importance of accurate contemporaneous records as part of patient care. From then, she made a point of reading her notes back to the consultant to ensure she had not omitted relevant information and ensured that her handover notes included all relevant details about treatment plans, outstanding actions and the patients who were greatest cause for concern. A few months later, the consultant made a point of praising the doctor for the effort she had made to improve.

Take-home messages

To support patient care, clinical records should accurately reflect what took place during a consultation and be made while events are fresh in your mind.
Never delete or overwrite a record – seek advice if you need to correct a factual inaccuracy or add information. It must be clear when and why this has been done and by whom.
Share all relevant information with colleagues during handovers, prioritising patients who are seriously unwell.
Use adverse incidents and feedback as opportunities for reflection and improvement.

Off the record

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