Record Keeping Concerns

CASE STUDY

Dr X is a salaried General Practitioner (‘GP’) who had been doing some locum sessions on their days off. In March 2022, Dr X was contacted by one of the GP Partners at the Practice where Dr X had been undertaking these locum sessions to advise that they had received some concerns about Dr X’s record keeping, which included: incomplete history taking for both physical and mental health problems, insufficient safety-netting for both physical and mental health problems and in some cases, no record of appropriate examination when patients were seen in face-to-face appointments with no recording of allergies (for example,. when prescribing antibiotics). 

As the concerns related to patient safety, Dr X was told that the matter would be referred to the local Performance Advisory Group (‘PAG’). Dr X subsequently received an email from NHS England/Improvement to advise that they had considered the concerns relating to Dr X’s record keeping, which were reviewed by the Case Assessment Team, and had decided that a Clinical Advisor was to undertake a records review and provide a report of their findings. Dr X was informed that they did not need to do anything at this stage. 

Dr X felt quite apprehensive about this. Dr X provided an explanation to MDS that they were much more familiar with SystemOne which they had used for over 20 years, as opposed to the EMIS system which was used at the Practice where Dr X had been undertaking locum sessions. Dr X clarified that it took some time to get used to this system and admitted that they occasionally forgot to click ‘save’ when documenting appointments. Dr X mentioned that at their usual workplace, they used SystemOne rather than EMIS, and as a result of this they had never been aware of any concerns there. 

The records review was carried out at Dr X’s usual workplace rather than the Practice at which they had been undertaking locum sessions, as that was the location where the majority of Dr X’s work was undertaken. An audit was carried out by an independent GP in relation to 50 of Dr X’s consultations and an investigation report was prepared. There were no serious concerns identified relating to patient harm, however some concerns were highlighted in 7 of the consultations. Nevertheless, none of Dr X’s consultations were deemed to be ‘unacceptable’.

MDS ADVICE & OUTCOME

A medicolegal advisor at MDS gave Dr X some guidance for generic scope for improvement and Dr X took this on board. Overall, Dr X showed insight and reflected on the Case Investigator’s feedback to improve their practice for future patients. Therefore, the Case Assessment Team was happy with Dr X’s engagement and comprehensive reflections and it was determined that there were no outstanding performance concerns. The case was closed and Dr X was advised to discuss this experience as part of their next annual appraisal for completion, to show how they had improved their practice of history taking, investigations, referrals and documentation. 

LEARNING POINTS

• Clear and accurate records support clinical decisions and patient care. Doctors are advised to document each patient interaction as soon as possible. If there are any concerns in relation to a doctor’s record keeping, they should consider attending a record-keeping course to improve their skills. MDS would be happy to share some beneficial courses with their members to assist, if required. 
• If a doctor is unfamiliar or inexperienced with a specific software used for patient record keeping, we would advise them to seek relevant training on this to assist with their future practice.