Dr Mark Burgin explains how analysing medical records from the perspective of an expert witness can help doctors improve how they write their notes.

Doctors strive to provide holistic care but this is not always easy to record; the more wide-ranging a consultation is, then the more difficult it might be to organise systematically. Good quality notes can speed up subsequent consultations and improve the chance that the doctor will remember the patient's 'story'.

Poorly written records can make it particularly difficult for other doctors stepping in to the patient's care to quickly understand what went before. The less information in the medical record, the more information that the patient has to remember and recount at subsequent consultations and the greater the risk of crossed wires and mistakes being made.

The four areas below outline how I analyse a record. Thinking about these areas when you make a record is likely to help you make sure you're covering all the essential points.

Clinical assessment

The expert looks at the doctor's clinical assessment of the medical condition by taking both the history and the examination together as a whole. A weak assessment is one where little is written, so that the history is sparse and relevant negatives and appropriate examination has been missed.

The expert will look at what is present and what is missing, meaning that doctors who write the diagnosis but do not show their thinking can be criticised.

When analysing your own records, one useful approach is to read the history and examination out loud and see whether it makes sense. Often the addition of a few words can change an inadequate and illogical entry into a professional statement.

Data interpretation

Data includes previous consultations, letters, test results and so on that may be relevant if properly interpreted. Data may give a doctor the opportunity to gain insights that are not possible from a standard history and examination. A patient may present a doctor with weeks of biometrics, information from the internet and comprehensive diary of symptoms, and this data can be overwhelming.

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Blood results, investigations and hospital letters can increase data overload, meaning the doctor is less able to pick up on cues or see patterns in the data, but good systems can reduce the time costs of data interpretation in the consultation. For example, having a system to ensure that blood tests include a clinical comment that can be read at the next consultation will save time in the long run.

The expert looks for evidence that the doctor has understood each issue raised by the data and addressed the legal and clinical significance. Ideally the doctor would have summarised the important findings, given clinical reasoning and provided a task list for the next consultation.

When reflecting on the quality of your own records, ask yourself how long it would take to interpret all the important data and whether that time can be shortened.

Recording patient involvement

When I am reviewing records in the context of a clinical negligence claim, assessing patient involvement usually focuses on consent and the information given to the patient.

The GMC's consent guidance has since 2008 set out specific expectations about what information a doctor must share with patients when seeking consent. The issue is rarely that the doctor does not get consent - it is that consent is integrated into the consultation and it is often difficult to find a way of recording it.

In their analysis the expert looks what the doctor has written about explanations, investigations, treatment and follow up, or as the GMC puts it, 'the decisions made and actions agreed' and, 'the information given to patients.'

Medical records do not always give a complete picture of a patient interaction. Some patients might not be compliant or might be difficult to communicate with because of language or other barriers. Despite these challenges, a doctor might face criticism or complaint if something goes wrong, so the doctor's records should clearly document the steps they have taken to address such difficulties.

Checking a patient's understanding of what has been said to them can be helpful when trying to evidence that the patient was properly informed. One approach to this is to record the patient's own words to show that the patient has understood what has been said to them, which can provide direct evidence of a meeting of minds.

Discussing with colleagues how they record consent can give ideas of how to narrow the gap between a doctor's good clinical skills and their records of patient involvement. This can all provide evidence to the expert of a broader approach of listening to the patient.

The expert will look at what is present and what is missing, meaning that doctors who write the diagnosis but do not show their thinking can be criticised.

Red flags

This term is used as short hand for specific symptoms or signs that are worrying. For example, chest pain is a red flag, as it worrying until it is made safe by diagnosing what is wrong or by taking reasonable steps to rule out serious illness.

Experts recognise that managing uncertainty is intrinsic to the role of a GP. An expert's task is to establish whether the GP acted in accordance with accepted practice and acted proportionately when assessing such risks. For example, it is proportionate to admit a 50-year old smoker with indigestion-like chest pain but not a 20-year old, so the presumption will be for admission in the former and against in the latter.

The records that a doctor makes when interpreting data (see above) may suggest to the expert that the doctor has not recognised an important clue or a comment from another practitioner. The records of patient involvement (the patient's view or advice given to them) may give an indication of whether the patient was aware of the problem and what they needed to do to stay safe.

However, when reflecting on your own records, it is perhaps more useful to look for direct evidence - have the red flags been listed? Have serious illnesses been reasonably excluded? Has safety netting advice been recording in clear and specific terms? The expert can be critical if the doctor has not made careful records showing they have taken reasonable steps to properly assess a red flag, and may also compare records with those of previous consultations with the same patient in order to determine how seriously the doctor took the patient's condition.

Top tips

  • Clinical records should make sense.
  • Good systems reduce data overload.
  • Record the patient's own words.
  • Make sure red flags are made safe.
  • Records should be proportionate to risk.

This page was correct at publication on 25/05/2018. 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.