Providing out-of-hours care to patients can pose considerable challenges for GPs, and each year the MDU sees a number of complaints and claims against doctors who deliver this service.
GPs might not have prior knowledge of the patient, or access to their full medical records. A greater emphasis on telephone triage can present challenges in diagnosis and treatment. A patient's expectations and anxiety levels may be high if they feel their condition is urgent.
However, there are various ways GPs working out-of-hours can minimise risk and avoid common pitfalls.
Delay in diagnosis
GPs often have to manage uncertainty and are generally well aware it's not always possible to rule out a serious underlying condition when assessed early on in an illness. However, it is important to review your diagnosis if the clinical course does not proceed as expected and not to become fixed on the first diagnosis, whether made by you or another clinician.
History taking and examination
Undertake a careful history and appropriate examination, and make detailed records. This will help to show management was of a reasonable standard. It is important to document the relevant negative findings, as well as the positive, in your history and examination – for example, absence of neck stiffness in a febrile patient.
Be aware that communication issues may arise. The out-of-hours setting is unfamiliar, and patients are usually seen by a doctor they have not met before. Patients may be more anxious than usual, and they can't compare their experience to previous episodes of care.
Perceived rudeness is a frequent trigger for a patient or relative to pursue a complaint against a GP, most commonly when there has been an unforeseen adverse outcome.
While this is an essential part of the patient assessment, it can present additional challenges in diagnosing and treating patients. Although calls are often recorded, make sure you record the same detailed clinical note that would be expected of a face-to-face consultation. Safety-netting advice often comes under scrutiny in claims; we advise you provide this in very clear terms and document it as comprehensively as possible.
While it's not necessary or practical to agree to every request for a visit, as with all consultations it is important to make careful and full records of the conversation (which in some cases may be recorded) when deciding whether a home visit is necessary. Again, it's essential to record your safety-netting advice in detail.
If you don't have access to the patient's full medical records, you may need to go back to basics in assessing a patient's background as well as the presenting complaint.
Record your management plan and a note of the instructions given to the patient very clearly within your clinical record. It is also important to explain to patients or relatives the expected course of the illness and the likely response time for treatment to take effect. You may consider writing these down for the patient.
If an adverse incident occurs, it is important to give the patient an explanation and apology as soon as possible. Adverse incidents should also be reviewed, perhaps through a significant event audit, to minimise the risk of a repeat error.
This guidance was correct at publication 23/09/2016. It 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.